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Cardona VQ, Byrne E, Mejia M, Joshi S, Menkiti O. Phenobarbital as a Sedation Strategy to Reduce Opioid and Benzodiazepine Burden in Neonatal Extracorporeal Membrane Oxygenation. Am J Perinatol 2024; 41:1586-1591. [PMID: 38365212 DOI: 10.1055/s-0044-1779255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
OBJECTIVE The study aims to describe our experience with the implementation of phenobarbital as a primary sedation strategy during neonatal extracorporeal membrane oxygenation (ECMO). STUDY DESIGN Retrospective chart review in a level IV neonatal intensive care unit between 2011 and 2021 comparing neonatal ECMO patients before and after the implementation of a sedation-analgesia (SA) protocol using scheduled phenobarbital as the primary sedative. Groups were compared for neonatal and ECMO characteristics, cumulative SA doses, and in-hospital outcomes. Comparison between groups was performed using Mann-Whitney test on continuous variables and chi-square on nominal variables. RESULTS Forty-two patients were included, 23 preprotocol and 19 postprotocol. Birth, pre-ECMO, and ECMO clinical characteristics were similar between groups except for a lower birth weight in the postprotocol group (p = 0.024). After standardization of phenobarbital SA protocol, there was a statistically significant reduction in median total morphine dose (31.38-17.65 mg/kg, p = 0.006) and median total midazolam dose (36.21-6.36 mg/kg, p < 0.001). There was also a reduction in median total days on morphine by 7.5 days (p = 0.026) and midazolam by 6.6 days (p = 0.003). There were no differences in ECMO duration or in-hospital outcomes between groups. CONCLUSION In this cohort, short-term use of phenobarbital as primary sedation strategy during neonatal ECMO was associated with reduced opioid and midazolam burden. Such reduction, however, did not affect in-hospital outcomes. KEY POINTS · Prolonged sedation on ECMO puts infants at risk for iatrogenic withdrawal.. · Phenobarbital is a feasible sedation strategy for ECMO.. · Phenobarbital sedation strategy may mitigate risk by decreasing opioid and midazolam burden..
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Affiliation(s)
- Vilmaris Quinones Cardona
- Division of Neonatology, Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
- Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Emma Byrne
- Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Michelle Mejia
- Division of Neonatology, Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Swosti Joshi
- Division of Neonatology, Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
- Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Ogechukwu Menkiti
- Division of Neonatology, Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
- Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania
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Lisonkova S, Wen Q, Richter LL, Ting JY, Lyons J, Mitchell-Foster S, Oviedo-Joekes E, Muraca GM, Bayrampour H, Cattoni E, Abrahams R. Neonatal abstinence syndrome and infant mortality and morbidity: a population-based study. Front Pediatr 2024; 12:1394682. [PMID: 39081925 PMCID: PMC11286564 DOI: 10.3389/fped.2024.1394682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 06/20/2024] [Indexed: 08/02/2024] Open
Abstract
Background Infant health among newborns with neonatal abstinence syndrome (NAS) has been understudied. We examined infant mortality and hospitalizations among infants diagnosed with NAS after birth. Methods All live births in British Columbia (BC), Canada, for fiscal years from 2004-2005 to 2019-2020, were included (N = 696,900). NAS was identified based on International Classification of Diseases, version 10, Canadian modification (ICD-10-CA) codes; the outcomes included infant death and hospitalizations during the first year of life, ascertained from BC linked administrative data. Generalized estimating equation models were used to adjust for maternal factors. Results There were 2,439 infants with NAS (3.50 per 1,000 live births). Unadjusted for other factors, infant mortality was 2.5-fold higher in infants with vs. without NAS (7.79 vs. 3.08 per 1,000 live births, respectively) due to increased post-discharge mortality NAS (5.76 vs. 1.34 per 1,000 surviving infants, respectively). These differences diminished after adjustment: adjusted odds ratio (AOR) for infant death was 0.85 [95% confidence interval (CI): 0.52-1.39]; AOR for post-discharge death was 1.75 (95% CI 1.00-3.06). Overall, 22.3% infants with NAS had at least one hospitalization after post-neonatal discharge, this proportion was 10.7% in those without NAS. During the study period, discharge to foster care declined from 49.5% to 20.3% in infants with NAS. Conclusion Unadjusted for other factors, infants with NAS had increased post-discharge infant mortality and hospitalizations during the first year of life. This association diminished after adjustment for adverse maternal and socio-medical conditions. Infants with NAS had a disproportionately higher rate of placement in foster care after birth, although this proportion declined dramatically between 2004/2005 and 2019/2020. These results highlight the importance of implementing integrated care services to support infants born with NAS and their mothers during the first year of life and beyond, even though NAS itself is not independently associated with increased infant mortality.
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Affiliation(s)
- Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Qi Wen
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay L. Richter
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Joseph Y. Ting
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Janet Lyons
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Sheona Mitchell-Foster
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
- Northern Medical Program, University of British Columbia, Prince George, BC, Canada
| | - Eugenia Oviedo-Joekes
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Giulia M. Muraca
- Departments of Obstetrics and Gynecology, and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Hamideh Bayrampour
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Eric Cattoni
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ronald Abrahams
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Miller JS, Bada HS, Westgate PM, Sithisarn T, Leggas M. Neonatal Abstinence Signs during Treatment: Trajectory, Resurgence and Heterogeneity. CHILDREN (BASEL, SWITZERLAND) 2024; 11:203. [PMID: 38397314 PMCID: PMC10887053 DOI: 10.3390/children11020203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 01/28/2024] [Accepted: 01/28/2024] [Indexed: 02/25/2024]
Abstract
Neonatal abstinence syndrome (NAS) presents with a varying severity of withdrawal signs and length of treatment (LOT). We examined the course and relevance of each of the NAS withdrawal signs during treatment in a sample of 182 infants with any prenatal opioid exposure, gestational age ≥ 35 weeks, without other medical conditions, and meeting the criteria for pharmacological treatment. Infants were monitored using the Finnegan Neonatal Abstinence Scoring Tool. Daily mean Finnegan scores were estimated using linear mixed models with random subject effects to account for repeated withdrawal scores from the same subject. Daily item prevalence was estimated using generalized estimating equations with a within-subject exchangeable correlation structure. The median LOT was 12.86 days. The prevalence of withdrawal signs decreased from day one to day three of treatment. However, certain central nervous system (CNS) and gastrointestinal (GI) signs showed sporadic increases in prevalence notable around two weeks of treatment, accounting for increases in Finnegan scores that guided pharmacotherapy. We question whether the resurgence of signs with a prolonged LOT is mainly a consequence of opioid tolerance or withdrawal. Monitoring CNS and GI signs throughout treatment is crucial. Future studies directed to better understand this clinical phenomenon may lead to the refining of NAS pharmacotherapy and perhaps the discovery of treatment alternatives.
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Affiliation(s)
- Jennifer S. Miller
- College of Nursing, University of Tennessee, Knoxville, TN 37996, USA;
- College of Medicine, University of Kentucky, Lexington, KY 40536, USA;
| | - Henrietta S. Bada
- College of Medicine, University of Kentucky, Lexington, KY 40536, USA;
| | - Philip M. Westgate
- College of Public Health, University of Kentucky, Lexington, KY 40536, USA;
| | | | - Markos Leggas
- Division of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA;
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Wang Y, Berger L, Durrance C, Kirby RS, Kuo D, Pac J, Ehrenthal DB. Duration and Timing of In Utero Opioid Exposure and Incidence of Neonatal Withdrawal Syndrome. Obstet Gynecol 2023; 142:603-611. [PMID: 37548391 PMCID: PMC10526694 DOI: 10.1097/aog.0000000000005289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/25/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE To evaluate the association between prenatal prescription opioid analgesic exposure (duration, timing) and neonatal opioid withdrawal syndrome (NOWS). METHODS We conducted a retrospective cohort study of Wisconsin Medicaid-covered singleton live births from 2011 to 2019. The primary outcome was a NOWS diagnosis in the first 30 days of life. Opioid exposure was identified with any claim for prescription opioid analgesic fills during pregnancy. We measured exposure duration cumulatively in days (1-6, 7-29, 30-89, and 90 or more) and identified timing as early (first two trimesters only) or late (third trimester, regardless of earlier pregnancy use). We used logistic regression modeling to assess NOWS incidence by exposure duration and timing, with and without propensity score matching. RESULTS Overall, 31,456 (14.3%) of 220,570 neonates were exposed to prescription opioid analgesics prenatally. Among exposed neonates, 19,880 (63.2%) had 1-6 days of exposure, 7,694 (24.5%) had 7-29 days, 2,188 (7.0%) had 30-89 days, and 1,694 (5.4%) had 90 or more days of exposure; 15,032 (47.8%) had late exposure. Absolute NOWS incidence among neonates with 1-6 days of exposure was 7.29 per 1,000 neonates (95% CI 6.11-8.48), and incidence increased with longer exposure: 7-29 days (19.63, 95% CI 16.53-22.73); 30-89 days (58.96, 95% CI 49.08-68.84); and 90 or more days (177.10, 95% CI 158.90-195.29). Absolute NOWS incidence for early and late exposures were 11.26 per 1,000 neonates (95% CI 9.65-12.88) and 35.92 per 1,000 neonates (95% CI 32.95-38.90), respectively. When adjusting for confounders including timing of exposure, neonates exposed for 1-6 days had no increased odds of NOWS compared with unexposed neonates, whereas those exposed for 30 or more days had increased odds of NOWS (30-89 days: adjusted odds ratio [aOR] 2.15, 95% CI 1.22-3.79; 90 or more days: 2.80, 95% CI 1.36-5.76). Late exposure was associated with elevated odds of NOWS (aOR 1.57, 95% CI 1.25-1.96) when compared with unexposed after adjustment for exposure duration. CONCLUSION More than 30 days of prenatal prescription opioid exposure was associated with NOWS regardless of exposure timing. Third-trimester opioid exposure, irrespective of exposure duration, was associated with NOWS.
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Affiliation(s)
- Yi Wang
- Social Science Research Institute, The Pennsylvania State University, University Park, PA
- Silberman School of Social Work, Hunter College, City University of New York, New York City, NY
| | - Lawrence Berger
- Sandra Rosenbaum School of Social Work and Institute for Research on Poverty, College of Letters and Sciences, University of Wisconsin-Madison, Madison, WI
| | - Christine Durrance
- La Follette School of Public Affairs, University of Wisconsin-Madison, Madison, WI
| | - Russell S. Kirby
- Chiles Center, College of Public Health, University of South Florida, Tampa, FL
| | - Daphne Kuo
- Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Jessica Pac
- Sandra Rosenbaum School of Social Work and Institute for Research on Poverty, College of Letters and Sciences, University of Wisconsin-Madison, Madison, WI
| | - Deborah B. Ehrenthal
- Social Science Research Institute, The Pennsylvania State University, University Park, PA
- Department of Biobehavioral Health, College of Health and Human Development, The Pennsylvania State University, University Park, PA
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Chanal C, Mazurier E, Doray B. Use of Psychoactive Substances during the Perinatal Period: Guidelines for Interventions during the Perinatal Period from the French National College of Midwives. J Midwifery Womens Health 2022; 67 Suppl 1:S17-S37. [PMID: 36480661 DOI: 10.1111/jmwh.13419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/10/2022] [Indexed: 12/13/2022]
Abstract
Based on their clinical practice and an extensive review of the literature, the authors propose a framework of procedures to be followed to provide services to all women of childbearing age who use psychoactive substances (alcohol, cannabis, cocaine, amphetamines, and opioids), especially during pregnancy or during the postpartum and breastfeeding periods, in view of their individual situations and environmental contexts.
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Affiliation(s)
- Corinne Chanal
- Hôpital Arnaud de Villeneuve, CHU Montpellier, 371 avenue du Doyen Gaston Giraud cedex 5, Montpellier, 34295, France.,Réseau de Périnatalité Occitanie Espace Henri BERTIN SANS, Bat A, 59 avenue de Fès-34080, Montpellier, France
| | - Evelyne Mazurier
- Hôpital Arnaud de Villeneuve, CHU Montpellier, 371 avenue du Doyen Gaston Giraud cedex 5, Montpellier, 34295, France
| | - Bérénice Doray
- Service de génétique, CHU de La Réunion, allée des Topazes, cedex, 97405, SAINT-DENIS.,Centre Ressource Troubles du Spectre de l'Alcoolisation Fœtale (TSAF) - Fondation Père Favron - 43 rue du Four à Chaux, Saint-Pierre, 97410, Réunion
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Leyenaar JK, Schaefer AP, Wasserman JR, Moen EL, O’Malley AJ, Goodman DC. Infant Mortality Associated With Prenatal Opioid Exposure. JAMA Pediatr 2021; 175:706-714. [PMID: 33843963 PMCID: PMC8042571 DOI: 10.1001/jamapediatrics.2020.6364] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Knowledge of health outcomes among opioid-exposed infants is limited, particularly for those not diagnosed with neonatal opioid withdrawal syndrome (NOWS). OBJECTIVES To describe infant mortality among opioid-exposed infants and identify how mortality risk differs in opioid-exposed infants with and without a diagnosis of NOWS compared with infants without opioid exposure. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of maternal-infant dyads was conducted, linking health care claims with vital records for births from January 1, 2010, to December 31, 2014, with follow-up of infants until age 1 year (through 2015). Maternal-infant dyads were included if the infant was born in Texas at 22 to 43 weeks' gestational age to a woman aged 15 to 44 years insured by Texas Medicaid. Data analysis was performed from May 2019 to October 2020. EXPOSURE The primary exposure was prenatal opioid exposure, with infants stratified by the presence or absence of a diagnosis of NOWS during the birth hospitalization. MAIN OUTCOMES AND MEASURES Risk of infant mortality (death at age <365 days) was examined using Kaplan-Meier and log-rank tests. A series of logistic regression models was estimated to determine associations between prenatal opioid exposure and mortality, adjusting for maternal and neonatal characteristics and clustering infants at the maternal level to account for statistical dependence owing to multiple births during the study period. RESULTS Among 1 129 032 maternal-infant dyads, 7207 had prenatal opioid exposure, including 4238 diagnosed with NOWS (mean [SD] birth weight, 2851 [624] g) and 2969 not diagnosed with NOWS (mean [SD] birth weight, 2971 [639] g). Infant mortality was 20 per 1000 live births for opioid-exposed infants not diagnosed with NOWS, 11 per 1000 live births for infants with NOWS, and 6 per 1000 live births in the reference group (P < .001). After adjusting for maternal and neonatal characteristics, mortality in infants with a NOWS diagnosis was not significantly different from the reference population (odds ratio, 0.82; 95% CI, 0.58-1.14). In contrast, the odds of mortality in opioid-exposed infants not diagnosed with NOWS was 72% greater than the reference population (odds ratio, 1.72; 95% CI, 1.25-2.37). CONCLUSIONS AND RELEVANCE In this study, opioid-exposed infants appeared to be at increased risk of mortality, and the treatments and supports provided to those diagnosed with NOWS may be protective. Interventions to support opioid-exposed maternal-infant dyads are warranted, regardless of the perceived severity of neonatal opioid withdrawal.
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Affiliation(s)
- JoAnna K. Leyenaar
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire,The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Andrew P. Schaefer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Jared R. Wasserman
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Erika L. Moen
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - David C. Goodman
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire,The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
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Neonatal Opioid Withdrawal Syndrome (NOWS): A Transgenerational Echo of the Opioid Crisis. Cold Spring Harb Perspect Med 2021; 11:cshperspect.a039669. [PMID: 32229609 DOI: 10.1101/cshperspect.a039669] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The incidence of neonatal opioid withdrawal syndrome (NOWS) has increased substantially in the setting of the opioid epidemic, a major public health problem in the United States. At present, NOWS has commonly used assessment and treatment protocols, but new protocols have questioned old practices. However, because of limited access to opioid use disorder (OUD) treatment and socioeconomic factors, many pregnant (and postpartum) women with OUD do not receive treatment. The pathophysiology of NOWS is not completely understood, although limited research studies have been conducted in humans and animals to better understand its etiology. Moreover, there is evidence that epigenetic and genetic factors play a role in the development of NOWS, but further study is needed. Animal models have suggested that there are deleterious effects of in utero opioid exposure later in life. Clinical research has revealed the harmful long-term sequelae of NOWS, with respect to cognitive function and childhood development. Many psychiatric disorders begin during adolescence, so as infants born with NOWS approach adolescence, additional clinical and molecular studies are warranted to identify biologic and psychosocial risk factors and long-term effects of NOWS. Additionally, access to specialized OUD treatment for pregnant women must be more readily available in the United States, especially in rural areas.
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Camden A, Ray JG, To T, Gomes T, Bai L, Guttmann A. Identification of Prenatal Opioid Exposure Within Health Administrative Databases. Pediatrics 2021; 147:peds.2020-018507. [PMID: 33376211 DOI: 10.1542/peds.2020-018507] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Health administrative data offer a vital source of data on maternal prenatal opioid exposure (POE). The impact of different methods to estimate POE, especially combining maternal and newborn records, is not known. METHODS This population-based cross-sectional study included 454 746 hospital births with linked administrative data in Ontario, Canada, in 2014-2017. POE ascertainment included 3 sources: (1) prenatal opioid prescriptions, (2) maternal opioid-related hospital records, and (3) newborn hospital records with neonatal abstinence syndrome (NAS). Positive percent agreement was calculated comparing cases identified by source, and a comprehensive method was developed combining all 3 sources. We replicated common definitions of POE and NAS from existing literature and compared both number of cases ascertained and maternal socio-demographics and medical history using the comprehensive method. RESULTS Using all 3 data sources, there were 9624 cases with POE (21.2 per 1000 births). Among these, positive percent agreement (95% confidence interval) was 79.0% (78.2-79.8) for prenatal opioid prescriptions, 19.0% (18.2-19.8) for maternal opioid-related hospital records, and 44.7% (43.7-45.7) for newborn NAS. Compared with other definitions, our comprehensive method identified up to 523% additional cases. Contrasting ascertainment with maternal opioid-related hospital records, newborn NAS, and prenatal opioid prescriptions respective rates of maternal low income were 57%, 48%, and 39%; mental health hospitalization history was 33%, 28%, and 17%; and infant discharge to social services was 8%, 13%, and 5%. CONCLUSIONS Combining prenatal opioid prescriptions and maternal and newborn opioid-related hospital codes improves identification of a broader population of mothers and infants with POE.
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Affiliation(s)
- Andi Camden
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,ICES, Toronto, Canada.,The Hospital for Sick Children, Toronto, Canada
| | - Joel G Ray
- ICES, Toronto, Canada.,The Hospital for Sick Children, Toronto, Canada.,Department of Obstetrics and Gynaecology and
| | - Teresa To
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,ICES, Toronto, Canada.,The Hospital for Sick Children, Toronto, Canada
| | - Tara Gomes
- ICES, Toronto, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada; and
| | | | - Astrid Guttmann
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; .,ICES, Toronto, Canada.,The Hospital for Sick Children, Toronto, Canada.,Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Canada
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