A cross-sectional study of breastfed infants referred for tongue tie assessment and frenotomy in one Canadian health region

Importance

Tongue tie (TT) is a condition that can cause infant feeding difficulties due to restricted tongue movement. When TT presents as a significant barrier to breastfeeding, a frenotomy may be recommended. Universally accepted diagnostic criteria for TT are lacking and wide prevalence estimates are reported. New referral processes and a Frenotomy Assessment Tool were implemented in one Canadian health region to connect breastfeeding dyads with a provider for TT evaluation and frenotomy.

Objective

To determine the proportion of babies with TT as well as the frequency of frenotomy.

Methods

This cross-sectional study included infants who initiated breastfeeding at birth and were referred for TT evaluation over a 14-month period. Data were collected retrospectively by chart review and analyzed using SPSS. Factors associated with frenotomy were examined using logistic regression.

Results

Two hundred and forty-one babies were referred. Ninety-two percent (n = 222) were diagnosed with TT and 66.0% (n = 159) underwent frenotomy. In the multivariate model, nipple pain/trauma, inability to latch, inability to elevate tongue, and dimpling of tongue on extension were associated with frenotomy (P < 0.05). Most referrals in our region resulted in a diagnosis of TT; however, the number of referrals was lower than expected, and of these two-thirds underwent frenotomy.

Interpretation

TT is a relatively common finding among breastfed infants. Future research should examine whether a simplified assessment tool containing the four items associated with frenotomy in our multivariate model can identify breastfed infants with TT who require frenotomy.

Mothers' experiences of breastfeeding a child with tongue‐tie

Tongue‐tie is characterized by an abnormally tight, short and thick lingual frenulum restricting the tongue's movement. This functional impairment can hinder a child's ability to maintain an effective latch and suckle and may lead to complex breastfeeding difficulties. The primary aim of this study was to explore the experiences of mothers who have breastfed a child with tongue‐tie, including their experiences with the health care system. A qualitative description study design was used. Two semistructured focus groups were conducted in February 2016 with a total of nine participants in the largest metropolitan area of Newfoundland and Labrador, Canada. Content analysis using constant comparison revealed a common incongruity between participants' breastfeeding expectations and their actual experiences of feeding a child with tongue‐tie. Three major themes are discussed: mothers' well‐being, strained interpersonal relationships and frustration with the health care system.

22 Parental Perceptions and Patterns of Cannabis Use During Pregnancy and Breastfeeding at a Canadian Tertiary Obstetrics Centre

Background

On October 17th, 2018, recreational cannabis use became legalized in Canada. Tetrahydrocannabinol (THC) is the main psychoactive compound in cannabis. It has the ability to cross the placenta and enter fetal tissues during pregnancy and accumulate in breast milk postpartum. There is limited research on the long-term effects of cannabis use, particularly on the developing brain. Canadian guidelines recommend that women who are thinking about becoming pregnant, are pregnant, or breastfeeding should abstain from using cannabis.

Objectives

The objective of this study was to investigate parental perceptions and patterns of cannabis use during the pre- and post-natal periods.

Design/Methods

Participants were recruited from the women’s health unit at a tertiary care centre; a total of 102 patients or partners of patients who were currently pregnant or less than 6 months post-partum were enrolled in the study. Participants consented to complete an anonymous, online questionnaire including previously validated demographic questions and newly developed questions on cannabis use during pregnancy and breastfeeding. Chi-square tests were used for data analysis.

Results

Overall, 5.0% of pregnant women and 6.3% of breastfeeding women used cannabis daily or weekly. Women who did not complete high school were significantly more likely to use cannabis during pregnancy than women who completed higher levels of education (p &lt; 0.001). Additionally, women who smoked cigarettes or vaped tobacco during pregnancy were significantly more likely to use cannabis during pregnancy (p &lt; 0.001; p &lt; 0.001). Among all participants, 22.6% and 30.4% believed there was no harm or were unsure of the harm associated with cannabis use during pregnancy and breastfeeding, respectively. Around half of the women who used cannabis during pregnancy or breastfeeding indicated that knowledge of the possible effects on the fetus or child would decrease their cannabis use. The majority of participants reported obtaining their information on cannabis use during breastfeeding from the internet (34.0%); while only 8.1% reported receiving information from a family doctor, 6.5% from an OBGYN, and 1.6% from a pediatrician. Legalization of cannabis had no reported effect on cannabis use during pregnancy and breastfeeding for the majority of participants.

Conclusion

It is clear that parents lack information about the safety of cannabis use during pregnancy and breastfeeding. Perinatal counselling should put an emphasis on educating parents on the risks associated with cannabis use during fetal development. In addition, given the overwhelming benefits of breastfeeding, harm reduction approaches to cannabis use while breastfeeding should be investigated.

Which Clinical Exam findings are most predictive of an abnormal hip ultrasound in the newborn? A chart review from a Canadian pediatric hospital

BACKGROUND

Developmental dysplasia of the hips is a condition that if not detected early and managed properly can lead to lifelong morbidity. The incidence of DDH in most developed countries is reported to be 1.5 to 20 cases per 1000 births. The Canadian Task Force on Preventive Health Care reports fair evidence to include a serial clinical examination of the hips by a trained clinician in the periodic health examination of all infants until they are walking independently. The indications for ultrasound examination are less clear. Guidelines for the clinical exam cite indications of imaging to be unstable hip, hip laxity, hip click and asymmetric skin folds. Given that some of these findings are extremely common it is likely that a large number of normal hips are being imaged unnecessarily.

OBJECTIVES

The purpose of this project is to determine which clinical findings are most predictive of an abnormal hip on ultrasound. It is hoped that this will assist the paediatrician or family doctor to balance unnecessary testing with the fear of missing an abnormal hip.

DESIGN/METHODS

All hip ultrasounds performed at a Canadian children’s hospital during 2016/17 on infants less than one year were reviewed for indication and outcome. The birth rate for the same year was 2,861. A total of 528 hip ultrasounds were performed. 156 ultrasounds were ordered by Paediatric Orthopaedic specialists and thus were not reviewed, leaving 372 ultrasounds for review. Ultrasounds were classified by age category at the time of imaging: <14 days, 14–28 days, 29–60 days, 61 days-6 months, 6 months-1 year. Tests were ordered by paediatricians, neonatologists, family doctors and nurse practitioners. The indications for ultrasound were categorized into 9 categories; hip click, hip laxity, unstable hip (positive Barlow, dislocatable hip), asymmetric skin folds, breech presentation, family history of DDH, hip click + breech, hip laxity + breech, or no indication given. When multiple terms were noted on requisition a hierarchy was followed with hip laxity>hip click>asymmetric skin folds. Ultrasound reports reported as normal or abnormal.

RESULTS

The primary indication for hip ultrasound was asymmetric skin folds, (N-132); followed by Hip laxity (N-101), Hip click (N-72), Unstable hip (positive Barlow, dislocatable hip) (N-31), no indication noted (N-23), Breech presentation (N-8), Family History of DDH (N-3) and other (N-2). The ultrasound findings with asymmetric skin folds revealed 100% of tests were normal (132/132) on first ultrasound regardless of baby’s age at imaging. For Hip laxity, 93% (94/101) ultrasounds were normal following second ultrasound and for hip click, 99% (71/72) were normal following second ultrasound. For those ultrasounds that were performed for hip click and hip laxity (N-173), only one ultrasound would have been required if performed at greater than 8 weeks of age. In the unstable hip, 82% (28/34) were normal following second ultrasound. None of the ultrasounds performed for risk factors such as family history or breech presentation were abnormal but when combined with a lax hip exam 3 were reported as abnormal. In our study, a diagnosis of DDH was given to 15/2,861 newborns. Of these 15; the clinical finding was 7/16 hip laxity alone, 6/16 unstable hip, 3/16 hip laxity + breech.

CONCLUSION

Though practitioners must continue to be vigilent in clinical hip surveillance, symmetric skin folds and isolated hip click are low yield indications for hip ultrasound in the newborn. For hip laxity or unstable hip, waiting until 8 weeks improves the reliability of the ultrasound result and thus reducing unnecessary retesting. The breech presentation alone did not increase diagnosis but when combined with exam was predictive.

Better Beginnings: At Risk Moms; What Are We Missing?

BACKGROUND: Since 2005, the number of infants born to mothers using substances has increased 4-fold in an eastern Canadian province. These babies may be at risk of medical problems including a withdrawal syndrome called “neonatal abstinence syndrome”. Previous research has shown that mothers using substances may experience increased rates of domestic violence, mental illness and housing and food insecurity. Currently, these determinants of health are not routinely recorded on medical charts of pregnant women who are patients at the province’s largest maternity facility.

OBJECTIVES: The primary goal of this study is to determine the prevalence of smoking, alcohol use, substance use, domestic violence and food/ housing insecurity in mothers delivering in an eastern Canadian province maternity hospital.

DESIGN/METHODS: This is a quantitative study involving all postpar-tum women delivering at the major delivery facility in province over a two month period (N=150). Participants were asked to complete an online, anonymous survey about their food/housing situation, domestic violence and substance use before and during pregnancy, as well as sociodemo-graphic questions.

RESULTS: Food and Housing Insecurity: The results of the study showed increased healthy eating behaviours during pregnancy; however the number of participants reliant on food banks remained at 4%. Our study found that while the majority of participants lived in a permanent residence, 2% of mothers used shelters or lived in a non-permanent residence. Mental health and Domestic Violence: While the majority of mother felt respected by their partner, family and friends, a significant amount reported feelings of isolation during pregnancy (12%). Women experiencing domestic violence stayed consistent before and during pregnancy at 2%. Smoking: Cigarette use in this population was slightly decreased from previous reports by the provincial perinatal program (12% vs. 14.9% reported) with rates of exposure to cigarette smoke much higher (24.7% vs. 6.4% reported). Alcohol use: Maternal reporting alcohol use during pregnancy was substantially increased from previous reports (13.3% vs. 0.9% reported). Those who reported consuming alcohol most frequently reported 1-2 drinks about 1-3 times per month. Substance Use: Currently, no reports within the province have captured the number of mothers using substances. This study shows approximately 5% of mothers using either marijuana, street/illicit drugs or methadone. Limitations: Mothers who did not speak English were excluded from the study.

CONCLUSION: The findings of this research indicate that important determinants of health are not being adequately recorded in Provincial databases thus programs are lacking.

Pediatric faculty and residents' perspectives on In-Training Evaluation Reports (ITERs)

BACKGROUND

In-training evaluation reports (ITERs) are used by over 90% of postgraduate medical training programs in Canada for resident assessment. Our study examined the perspectives of faculty and residents in one pediatric program as a means to improve the ITER as an evaluation tool.

METHOD

Two separate focus groups were conducted, one with eight pediatric residents and one with nine clinical faculty within the pediatrics program of Memorial University's Faculty of Medicine to discuss their perceptions of, and suggestions for improving, the use of ITERs.

RESULTS

Residents and faculty shared many similar suggestions for improving the ITER as an evaluation tool. Both the faculty and residents emphasized the importance of written feedback, contextualizing the evaluation and timely follow-up. The biggest challenge appears to be the discrepancy in the quality of feedback sought by the residents and the faculty members' ability to do so in a time effective manner. Others concerns related to the need for better engagement in setting rotation objectives and more direct observation by the faculty member completing the ITER.

CONCLUSIONS

The ITER is a useful tool in resident evaluations, but a number of issues relating to its actual use could improve the quality of feedback which residents receive.

A randomized controlled study of manikin simulator fidelity on neonatal resuscitation program learning outcomes

The neonatal resuscitation program (NRP) has been developed to educate physicians and other health care providers about newborn resuscitation and has been shown to improve neonatal resuscitation skills. Simulation-based training is recommended as an effective modality for instructing neonatal resuscitation and both low and high-fidelity manikin simulators are used. There is limited research that has compared the effect of low and high-fidelity manikin simulators for NRP learning outcomes, and more specifically on teamwork performance and confidence. The purpose of this study was to examine the effect of using low versus high-fidelity manikin simulators in NRP instruction. A randomized posttest-only control group study design was conducted. Third year undergraduate medical students participated in NRP instruction and were assigned to an experimental group (high-fidelity manikin simulator) or control group (low-fidelity manikin simulator). Integrated skills station (megacode) performance, participant satisfaction, confidence and teamwork behaviour scores were compared between the study groups. Participants in the high-fidelity manikin simulator instructional group reported significantly higher total scores in overall satisfaction (p = 0.001) and confidence (p = 0.001). There were no significant differences in teamwork behaviour scores, as observed by two independent raters, nor differences on mandatory integrated skills station performance items at the p < 0.05 level. Medical students' reported greater satisfaction and confidence with high-fidelity manikin simulators, but did not demonstrate overall significantly improved teamwork or integrated skills station performance. Low and high-fidelity manikin simulators facilitate similar levels of objectively measured NRP outcomes for integrated skills station and teamwork performance.

Adherence to management of high blood pressure: recommendations of the Canadian Coalition for High Blood Pressure Prevention and Control

Adherence or compliance, in the context of medical treatment, refers to how well a patient follows and sticks to the management plan developed with her/his health care provider, which may include pharmacologic agents as well as changes in lifestyle. Adherence is of great concern in asymptomatic conditions such as hypertension, where lack of control may have serious ramifications including end organ damage and premature mortality. To address this issue, the Canadian Coalition for High Blood Pressure Prevention and Control established a national Advisory Committee on Adherence to the Management of High Blood Pressure. The Advisory Committee consisted of 11 members from different disciplines of health care providers. The Committee reviewed all evidences to date and drew up four practical recommendations with respect to patient, provider and environment. Based on Canadian Task Force on Periodic Health Examination's guidelines, all four recommendations can be classified as 'level C' with a quality of evidence of II.

Adherence to pharmacologic management of hypertension

Adherence to pharmacologic therapy of hypertension is low (in the range of 50-70%) and has important implications both for blood pressure control and cardiovascular complications. Based on a review of the literature using the levels of evidence grading technique, determinants of adherence to the pharmacologic therapy of hypertension have been assessed. Additionally, interventions to improve compliance were evaluated. Patient-centred, health care provider-centred and drug-specific factors have all been shown to affect adherence rates. We conclude that the extent of adherence to pharmacologic therapy is modifiable. Measurable improvements in adherence can be obtained from simplified medication regimens and a combination of behaviour strategies, including the tailoring of pill-taking to patients' daily habits and rituals, the advocacy of self-monitoring of pills and blood pressure, and the institution of reward systems.

A comparison of the side effects of atenolol and propranolol in the treatment of patients with hypertension

A single-blind study was conducted in 52 hypertensive patients, aged 25 to 68 years, to compare the side effects of an equally effective antihypertensive regimen of propranolol and atenolol. All patients had a history of side effects with beta-blocker therapy. Patients were treated with propranolol 40 to 160 mg bid for 8 weeks, followed by atenolol 50 to 100 mg given once daily for 8 weeks, and then rechallenged with the required dosage of propranolol for 8 weeks. Mean systolic and diastolic blood pressures were controlled during all three treatment phases. Side effects showed a definite trend toward improvement during the atenolol treatment phase. CNS side effects, in particular, showed significantly (P less than .05) reduced severity scores and overall incidence rates during the atenolol treatment phase. In conclusion, this study showed that at equally effective antihypertensive dosages the hydrophilic beta blocker atenolol produced significantly fewer CNS side effects than the lipophilic beta blocker propranolol.