E-mail communication in paediatrics: Ethical and clinical considerations

E-mail has become a commonplace ‘procedure’ in medical practice because it is efficient and inexpensive. However, there are potential misuses and abuses of this form of written communication, with clinical and ethical implications. Common uses of e-mail in paediatics include general communication with colleagues in a professional setting; electronic formal consultation, in which patient confidentiality is paramount; electronic ‘curbside’ consultation, which may be perceived as a formal consultation; electronic discussion groups, which lack peer review; communication with current patients or their parents, which should be limited to simple, nonurgent issues; and communication with individuals seeking medical advice who are not patients, which is generally ill-advised. The present practice point offers a few practical suggestions including e-mail etiquette, security measures to ensure confidentiality, development of an e-mail policy for patients and parents, and separation of personal from professional e-mail. Le courriel est devenu une « intervention » courante en médecine parce qu’il est efficace et peu coûteux. Cependant, un potentiel de mésusage et d’abus s’associe à cette forme de communication écrite, qui a des répercussions cliniques et éthiques. L’utilisation courante du courriel en pédiatrie inclut des communications d’ordre général avec des consœurs et des confrères en milieu professionnel, des consultations électroniques officielles, dans le cadre desquelles la confidentialité des patients est primordiale, des consultations électroniques « au pied levé », qui peuvent être perçues comme des consultations officielles, des groupes de discussion électronique, sans révision par des pairs, des communications avec les patients ou leurs parents, qui devraient se limiter à des questions simples et non urgentes, et des communications avec des personnes qui cherchent à obtenir des conseils médicaux et qui ne sont pas des patients, ce qui est généralement mal avisé. Le présent point de pratique contient quelques suggestions pratiques, y compris la nétiquette, les mesures de sécurité pour garantir la confidentialité, la mise au point d’une politique de courriels à l’intention des patients et des parents et la séparation entre les courriels personnels et professionnels

The relationship between paediatric practitioners and ‘industry’

Paediatric practitioners interact with industry representatives for many purposes but most often to receive information on new and existing products. While practitioners believe they are immune to the marketing influences exerted by these representatives, research has demonstrated otherwise. The literature suggests that the public is aware of such influences and that most people feel industry influence on practitioners is inappropriate. National guidelines go some way toward regulating practitioner–industry interactions, although they are not always clear or sufficient. The present practice point explores the context for these relationships, raises some ethical issues specific to paediatric practitioners and provides recommendations for maintaining professional integrity in the patient–physician relationship. Paediatric practitioners have a professional duty to ensure that their own interactions with industry are conducted with the best interests of the patient front and centre

Matters of life and death in the neonatal intensive care unit : decision-making for the non-yet-competent

Neonatology is a branch of paediatrics dealing with extremely ill or premature babies, and the neonatal intensive care unit (NICU) is frequently the setting for life-and-death decisions. Society considers parents to be the proper persons to make those decisions for their babies, but in practice they seem to be allowed to do this only as long as they agree with medical recommendations; otherwise, the "best interest standard" is proposed. My objective is to evaluate decision-making in the NICU. Part I of this research, a descriptive study, compares decision-making by parents, doctors, and nurses when presented with hypothetical scenarios. Part II, through in-depth interviews, evaluates factors important to parents in making life-anddeath decisions. Part III, using structured interviews, explores the neonatologists' perceptions of the limits of parental decision-making authority. The results reveal that parents make different decisions from those of doctors and nurses. Parents have an equal commitment to intensive care (35-40%) with either mental or physical handicap. Doctors and nurses, on the other hand, have less commitment to intensive care with severe mental handicap (10%), but more commitment with physical handicap (90%). Religious commitment and experience with handicap influence decisions by parents, but not by doctors and nurses. The right of parents to decide for their baby and the interests of the family are also more important for parents than for doctors and nurses. For parents, furthermore, the important factors are an honest, caring, transparent relationship with good communication with their neonatologist; being fully informed; their values and beliefs; their roles and their sense of loss of control; and emotional turmoil. Of these interrelated factors, the most important is the relationship between parents and doctors. For parents, quality of life considerations are individual. For all study participants, the interests of the baby are most important. According to neonatologists, parents are the appropriate decision-makers, but within limits. It is concluded that not only do parents make different decisions.from those of doctors and nurses, but that several concerns in the decision-making process in our NICU require urgent attention.Graduate and Postdoctoral StudiesGraduat

Pandemic planning : Developing a triage framework for Neonatal Intensive Care Unit

Although the Covid-19 pandemic has not had a direct impact on neonates so far, it has raised concerns about resource distribution and showed that planning is required before the next crisis or pandemic. Resource allocation must consider unique Neonatal Intensive Care Unit (NICU) attributes, including physical space and equipment that may not be transferable to older populations, unique skills of NICU staff, inherent uncertainty in prognosis both antenatally and postnatally, possible biases against neonates, and the future pandemic disease’s possible impact on neonates. We identified the need for a validated Neonatal Severity of Illness Prognostic Score to guide triage decisions. Based on this score, triage decisions are the responsibility of an informed triage team not involved in direct patient care. Support for the distress experienced by parents and staff is needed. This paper presents essential considerations in developing a practical framework for resources and triage in the NICU before, during and after a pandemic.Medicine, Faculty ofNon UBCPediatrics, Department ofReviewedFacult

Relationships among Different Water-Soluble Choline Compounds Differ between Human Preterm and Donor Milk

Choline is essential for infant development. Human milk choline is predominately present in three water-soluble choline (WSC) forms: free choline (FC), phosphocholine (PhosC), and glycerophosphocholine (GPC). It is unclear whether mother’s own preterm milk and pooled donor milk differ in WSC composition and whether WSC compounds are interrelated. Mother’s own preterm milk (n = 75) and donor milk (n = 30) samples from the neonatal intensive care unit, BC Women’s Hospital were analyzed for WSC composition using liquid chromatography tandem mass spectrometry (LC-MS/MS). Associations between different WSC compounds were determined using Pearson’s correlations, followed by Fischer r-to-z transformation. Total WSC concentration and concentrations of FC, PhosC, and GPC did not significantly differ between mother’s own milk and donor milk. FC was negatively associated with PhosC and GPC in mother’s own milk (r = −0.27, p = 0.02; r = −0.34, p = 0.003, respectively), but not in donor milk (r = 0.26, p = 0.181 r = 0.37, p = 0.062, respectively). The difference in these associations between the two milk groups were statistically significant (p = 0.03 for the association between PhosC and FC; and p = 0.003 for the association between FC and GPC). PhosC and GPC were positively associated in mother’s own milk (r = 0.32, p = 0.036) but not donor milk (r = 0.36, p = 0.062), although the difference in correlation was not statistically significant. The metabolic and clinical implications of these associations on the preterm infant need to be further elucidated.Medicine, Faculty ofOther UBCNon UBCPediatrics, Department ofPopulation and Public Health (SPPH), School ofReviewedFacult

Evaluation of A Concentrated Preterm Formula as a Liquid Human Milk Fortifier in Preterm Babies at Increased Risk of Feed Intolerance

There are concerns around safety and tolerance of powder human milk fortifiers to optimize nutrition in preterm infants. The purpose of this study was to evaluate the tolerance and safety of a concentrated preterm formula (CPF) as a liquid human milk fortifier (HMF) for premature infants at increased risk of feeding intolerance. We prospectively enrolled preterm infants over an 18-month period, for whom a clinical decision had been made to add CPF to human milk due to concerns regarding tolerance of powder HMF. Data on feed tolerance, anthropometry, and serum biochemistry values were recorded. Serious adverse events, such as mortality, necrotizing enterocolitis (NEC), and sepsis, were monitored. A total of 29 babies received CPF fortified milk during the study period. The most common indication for starting CPF was previous intolerance to powder HMF. Feeding intolerance was noted in 4 infants on CPF. The growth velocity of infants was satisfactory (15.9 g/kg/day) after addition of CPF to feeds. The use of CPF as a fortifier in preterm babies considered at increased risk for feed intolerance seems well tolerated and facilitates adequate growth. Under close nutrition monitoring, this provides an additional option for human milk fortification in this challenging subgroup of preterm babies, especially in settings with limited human milk fortifier options.Medicine, Faculty ofOther UBCPediatrics, Department ofPopulation and Public Health (SPPH), School ofReviewedFacult

Human Milk Calorie Guide: A Novel Color-Based Tool to Estimate the Calorie Content of Human Milk for Preterm Infants

Fixed-dose fortification of human milk (HM) is insufficient to meet the nutrient requirements of preterm infants. Commercial human milk analyzers (HMA) to individually fortify HM are unavailable in most centers. We describe the development and validation of a bedside color-based tool called the ‘human milk calorie guide’(HMCG) for differentiating low-calorie HM using commercial HMA as the gold standard. Mothers of preterm babies (birth weight ≤ 1500 g or gestation ≤ 34 weeks) were enrolled. The final color tool had nine color shades arranged as three rows of three shades each (rows A, B, and C). We hypothesized that calorie values for HM samples would increase with increasing ‘yellowness’ predictably from row A to C. One hundred thirty-one mother’s own milk (MOM) and 136 donor human milk (DHM) samples (total n = 267) were color matched and analyzed for macronutrients. The HMCG tool performed best in DHM samples for predicting lower calories (70 kcal/dL (AUC 0.77 for category C DHM). For MOM, its diagnostic performance was poor. The tool showed good inter-rater reliability (Krippendorff’s alpha = 0.80). The HMCG was reliable in predicting lower calorie ranges for DHM and has the potential for improving donor HM fortification practices