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Cucka B, Biglione B, Xia J, Tan AJ, Chand S, Rrapi R, El Saleeby C, Kroshinsky D. Complicated Cellulitis is an Independent Predictor for Increased Length of Stay in the Neonatal Intensive Care Unit. J Pediatr 2023; 262:113581. [PMID: 37353147 DOI: 10.1016/j.jpeds.2023.113581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 05/23/2023] [Accepted: 06/16/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE To assess cellulitis in the neonatal intensive care unit (NICU) setting and identify risk factors for its disease severity and whether cellulitis influences length of stay (LOS). STUDY DESIGN In this retrospective study, patients with cellulitis were identified using the electronic health record while admitted to the NICU at Massachusetts General for Children from January 2007 to December 2020. Demographic and clinical data were extracted from patient records. Two multivariable logistic regression models were constructed to assess for independent predictors for increased LOS (≥30 days) and complicated cellulitis in the hospital. RESULTS Eighty-four patients met the study criteria; 46.4% were older than 14 days at the time of diagnosis of cellulitis, 61.9% were non-White, and 83.3% were born prematurely; 48.8% had complicated cellulitis as defined by overlying hardware (41.7%), sepsis (7.1%), requirement for broadened antibiotic coverage (7.1%), bacteremia (4.8%), and/or abscess (3.6%). The mean hospital LOS was 58.5 ± 36.1 days SD, with 72.6% having a LOS greater than 30 days. Independent predictors of increased LOS were extreme prematurity (<28 weeks' gestation) (OR: 14.7, P = .03), non-White race (OR: 5.7, P = .03), and complicated cellulitis (OR: 6.4, P = .03). No significant predictors of complicated cellulitis were identified. CONCLUSIONS This study identifies complicated cellulitis in the NICU as an independent predictor of increased hospital LOS in neonates. Implementation of strategies to mitigate the development of cellulitis may decrease LOS among this high-risk population.
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Affiliation(s)
- Bethany Cucka
- Department of Dermatology, Massachusetts General Hospital, Boston, MA
| | - Bianca Biglione
- Department of Dermatology, Massachusetts General Hospital, Boston, MA
| | - Joyce Xia
- Department of Dermatology, Massachusetts General Hospital, Boston, MA
| | - Alice J Tan
- Department of Dermatology, Massachusetts General Hospital, Boston, MA
| | - Sidharth Chand
- Department of Dermatology, Massachusetts General Hospital, Boston, MA
| | - Renajd Rrapi
- Department of Dermatology, Massachusetts General Hospital, Boston, MA
| | - Chadi El Saleeby
- Divisions of Hospital Medicine and Infectious Disease, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA; Harvard Medical School, Boston, MA
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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Hanna M, Shah R, Marquez L, Barzegar R, Gordon A, Pammi M. Infant isolation and cohorting for preventing or reducing transmission of healthcare-associated infections in neonatal units. Cochrane Database Syst Rev 2023; 6:CD012458. [PMID: 37368649 PMCID: PMC10297826 DOI: 10.1002/14651858.cd012458.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
BACKGROUND Neonatal healthcare-associated infections (HAIs) result in increased morbidity and mortality, as well as increased healthcare costs. Patient isolation measures, i.e. single-room isolation or the cohorting of patients with similar infections, remain a recommended and commonly used practice for preventing horizontal spread of infections in the neonatal intensive care unit (NICU). OBJECTIVES: Our primary objective was to assess the effect of single-room isolation or cohorting, or both for preventing transmission of HAIs or colonization with HAI-causing pathogens in newborn infants less than six months of age admitted to the neonatal intensive care unit (NICU). Our secondary objective was to assess the effect of single-room isolation or cohorting, or both on neonatal mortality and perceived or documented adverse effects in newborn infants admitted to the NICU. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, the WHO ICTRP and ClinicalTrials.gov trials registries. There were no restrictions to date, language or publication type. We also checked the reference lists of studies identified for full-text review. SELECTION CRITERIA: Types of studies: cluster-randomized or quasi-randomized trials at the level of the cluster (where clusters may be defined by NICU, hospital, ward, or other subunits of the hospital). We also included cross-over trials with a washout period of more than four months (arbitrarily defined). TYPES OF PARTICIPANTS newborn infants less than six months of age in neonatal units that implemented patient isolation or cohorting as infection control measures to prevent HAIs. Types of interventions: patient isolation measures (single-room isolation or cohorting, or both of infants with similar colonization or infections) compared to routine isolation measures. TYPES OF OUTCOME MEASURES the primary outcome was the rate of transmission of HAIs as estimated by the infection and colonization rates in the NICU. Secondary outcomes included all-cause mortality during hospital stay at 28 days of age, length of hospital stay, as well as potential adverse effects of isolation or cohorting measures, or both. DATA COLLECTION AND ANALYSIS The standard methods of Cochrane Neonatal were used to identify studies and assess the methodological quality of eligible cluster-randomized trials. The certainty of the evidence was to be assessed by the GRADE method as evidence of high, moderate, low, or very low certainty. Infection and colonization rates were to be expressed as rate ratios for each trial and if appropriate for meta-analysis, the generic inverse variance method in RevMan was to be used. MAIN RESULTS We did not identify any published or ongoing trials to include in the review. AUTHORS' CONCLUSIONS The review found no evidence from randomized trials to either support or refute the use of patient isolation measures (single-room isolation or cohorting) in neonates with HAIs. Risks secondary to infection control measures need to be balanced against the benefits of decreasing horizontal transmission in the neonatal unit for optimal neonatal outcomes. There is an urgent need to research the effectiveness of patient isolation measures for preventing the transmission of HAIs in neonatal units. Well-designed trials randomizing clusters of units or hospitals to a type of patient isolation method intervention are warranted.
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Affiliation(s)
- Morcos Hanna
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, USA
| | - Rita Shah
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, USA
| | - Lucila Marquez
- Department of Pediatric Infectious Diseases, Baylor College of Medicine, Houston, USA
| | - Rebecca Barzegar
- RPA Newborn Care, Sydney Local Health District, Sydney, Australia
| | - Adrienne Gordon
- RPA Newborn Care, Sydney Local Health District, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Mohan Pammi
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, USA
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Böhne C, Knegendorf L, Schwab F, Ebadi E, Bange FC, Vital M, Schlüter D, Hansen G, Pirr S, Peter C, Bohnhorst B, Baier C. Epidemiology and infection control of Methicillin-resistant Staphylococcus aureus in a German tertiary neonatal intensive and intermediate care unit: A retrospective study (2013-2020). PLoS One 2022; 17:e0275087. [PMID: 36129948 PMCID: PMC9491611 DOI: 10.1371/journal.pone.0275087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 09/10/2022] [Indexed: 11/25/2022] Open
Abstract
In preterm and term infants who require intermediate or intensive care Methicillin-resistant Staphylococcus aureus (MRSA) infection can lead to significant morbidity. In this study MRSA colonization and infection were assessed in a mixed tertiary neonatal intensive and intermediate care unit in Germany over an 8-year period (2013-2020). We investigated patient-related factors, associated with nosocomial MRSA acquisition, and we discuss our infection control concept for MRSA. Of 3488 patients treated during the study period, 24 were MRSA positive patients, corresponding to 26 patient hospital stays. The incidence was 0.7 MRSA patients per 100 patients. The incidence density was 0.4 MRSA patient hospital stays per 1000 patient days. Twelve patients (50%) acquired MRSA in the hospital. One patient developed a hospital acquired MRSA bloodstream infection 9 days after birth (i.e., 0.03% of all patients on the ward during the study period). A total of 122 patients had to be screened to detect one MRSA positive patient. In a logistic regression model, the use of 3rd generation intravenous cephalosporin (cefotaxim) was associated with nosocomial MRSA acquisition compared with matched control patients who did not acquire MRSA. In sum, the burden of MRSA colonization and infection in the ward was low during the study period. A comprehensive infection control concept that included microbiologic colonization screening, prospective infection surveillance together with isolation and emphasis on basic hygiene measures is essential to handle MRSA in this specialized setting.
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Affiliation(s)
- Carolin Böhne
- Department of Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School (MHH), Hannover, Germany
| | - Leonard Knegendorf
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School (MHH), Hannover, Germany
| | - Frank Schwab
- Institute of Hygiene and Environmental Medicine, Charité - University Medicine, Berlin, Germany
| | - Ella Ebadi
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School (MHH), Hannover, Germany
| | - Franz-Christoph Bange
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School (MHH), Hannover, Germany
| | - Marius Vital
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School (MHH), Hannover, Germany
| | - Dirk Schlüter
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School (MHH), Hannover, Germany
| | - Gesine Hansen
- Department of Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School (MHH), Hannover, Germany
| | - Sabine Pirr
- Department of Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School (MHH), Hannover, Germany
| | - Corinna Peter
- Department of Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School (MHH), Hannover, Germany
| | - Bettina Bohnhorst
- Department of Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School (MHH), Hannover, Germany
| | - Claas Baier
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School (MHH), Hannover, Germany
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Nourollahpour Shiadeh M, Sepidarkish M, Mollalo A, As'adi N, Khani S, Shahhosseini Z, Danesh M, Esfandyari S, Mokdad AH, Rostami A. Worldwide prevalence of maternal methicillin-resistant Staphylococcus aureus colonization: A systematic review and meta-analysis. Microb Pathog 2022; 171:105743. [PMID: 36044936 DOI: 10.1016/j.micpath.2022.105743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) infection during pregnancy can adversely influence the well-being of pregnant women, fetuses, and neonates. To our knowledge, there is no global data on the maternal prevalence of MRSA colonization. We conducted a systematic review and meta-analysis to estimate the global and regional prevalence rates of MRSA colonization among pregnant women. We searched international databases (i.e., MEDLINE/PubMed, EMBASE, Scopus, Web of Science collection, and SciELO) for studies published from inception to March 10, 2022. Observational population-based studies reporting MRSA colonization among pregnant women were eligible to be included. We utilized the random-effects meta-analyses to compute the pooled prevalence estimates of maternal colonization across studies at 95% confidence intervals (CIs). The heterogeneity was assessed by I2 statistic and the Cochran's Q test. Subgroup and meta-regression analyses were used to adjust for potential sources of heterogeneity. The data source regarding maternal MRSA colonization included 55 studies from 24 countries and 110,654 pregnant women. The worldwide pooled prevalence for maternal MRSA colonization was 3.23% (95% CI, 2.40-4.17%), with the highest and lowest colonization rates for Africa (9.13%, 4.36-15.34%) and Europe (0.79%, 0.28-1.51%), respectively. We estimated that nearly 4.5 million pregnant women are colonized with MRSA worldwide. MRSA colonization rates were higher among black ethnicity, multiparous women, pregnant women with prior MRSA infection, women with lower personal hygiene, and those living in lower-income and human development indices countries or regions. MRSA colonizes substantial numbers of pregnant women worldwide, with varying prevalence rates in different regions; however, further investigations are needed to recognize regional differences. Our findings emphasized the need for prevention efforts against MRSA to reduce the health risks among women and newborns.
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Affiliation(s)
| | - Mahdi Sepidarkish
- Department of Biostatistics and Epidemiology, School of Public Health, Babol University of Medical Sciences, Babol, Iran
| | - Abolfazl Mollalo
- Department of Public Health and Prevention Science, School of Health Sciences, Baldwin Wallace University, Berea, OH, USA
| | - Nayereh As'adi
- Department of Midwifery, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Soghra Khani
- Sexual and Reproductive Health Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Zohreh Shahhosseini
- Sexual and Reproductive Health Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahmonir Danesh
- Sexual and Reproductive Health Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Sahar Esfandyari
- Department of Urology, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Ali H Mokdad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Ali Rostami
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
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Molina García A, Cross JH, Fitchett EJ, Kawaza K, Okomo U, Spotswood NE, Chiume M, Ezeaka VC, Irimu G, Salim N, Molyneux EM, Lawn JE. Infection prevention and care bundles addressing health care-associated infections in neonatal care in low-middle income countries: a scoping review. EClinicalMedicine 2022; 44:101259. [PMID: 35059614 PMCID: PMC8760419 DOI: 10.1016/j.eclinm.2021.101259] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Health care-associated infections (HCAI) in neonatal units in low- and middle-income countries (LMIC) are a major cause of mortality. This scoping review aimed to synthesise published literature on infection prevention and care bundles addressing neonatal HCAI in LMICs and to construct a Classification Framework for their components (elements). METHODS Five electronic databases were searched between January 2001 and July 2020. A mixed-methods approach was applied: qualitative content analysis was used to build a classification framework to categorise bundle elements and the contents of the classification groups were then described quantitatively. FINDINGS 3619 records were screened, with 44 eligible studies identified. The bundle element Classification Framework created involved: (1) Primary prevention, (2) Detection, (3) Case management, and Implementation (3 + I). The 44 studies included 56 care bundles with 295 elements that were then classified. Primary prevention elements (128, 43%) predominated of which 71 (55%) focused on central line catheters and mechanical ventilators. Only 12 elements (4%) were related to detection. A further 75 (25%) elements addressed case management and 66 (88%) of these aimed at outbreak control. INTERPRETATION The 3 + I Classification Framework was a feasible approach to reporting and synthesising research for infection-relevant bundled interventions in neonatal units. A shift towards the use in infection prevention and care bundles of primary prevention elements focused on the neonate and on commonly used hospital devices in LMIC (e.g., self-inflating bags, suctioning equipment) would be valuable to reduce HCAI transmission. Detection elements were a major gap. FUNDING This work was made possible in part by the John D. and Catherine T. MacArthur Foundation, the Bill & Melinda Gates Foundation, ELMA Philanthropies, The Children's Investment Fund Foundation UK, The Lemelson Foundation, and the Ting Tsung and Wei Fong Chao Foundation under agreements to William Marsh Rice University. The project leading to these results has also received the support of a fellowship from the "la Caixa" Foundation (ID 100010434). The fellowship code is LCF/BQ/EU19/11710040. EJAF is an Academic Clinical Fellow whose salary is funded by the UK National Institute for Health Research (NIHR). NES receives a Research Training Program Scholarship (Australian Commonwealth Government).
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Affiliation(s)
| | - James H. Cross
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Kondwani Kawaza
- Department of Paediatrics, Kamuzu University of Health Sciences (formerly College of Medicine, University of Malawi), Blantyre, Malawi
| | - Uduak Okomo
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Naomi E. Spotswood
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - Msandeni Chiume
- Department of Paediatrics, Kamuzu University of Health Sciences (formerly College of Medicine, University of Malawi), Blantyre, Malawi
| | | | - Grace Irimu
- Department of Paediatrics and Child Health, University of Nairobi, Kenya
| | - Nahya Salim
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Elizabeth M. Molyneux
- Department of Paediatrics, Kamuzu University of Health Sciences (formerly College of Medicine, University of Malawi), Blantyre, Malawi
| | - Joy E. Lawn
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - with the NEST360 Infection Prevention, Detection and Care Collaborative Group
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
- UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Paediatrics, Kamuzu University of Health Sciences (formerly College of Medicine, University of Malawi), Blantyre, Malawi
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Paediatrics, College of Medicine, University of Lagos, Nigeria
- Department of Paediatrics and Child Health, University of Nairobi, Kenya
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
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Branstetter JW, Barker L, Yarbrough A, Ross S, Stultz JS. Challenges of Antibiotic Stewardship in the Pediatric and Neonatal Intensive Care Units. J Pediatr Pharmacol Ther 2021; 26:659-668. [PMID: 34588929 DOI: 10.5863/1551-6776-26.7.659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 07/01/2021] [Indexed: 12/14/2022]
Abstract
The goals of antimicrobial stewardship programs (ASPs) are to optimize antimicrobial prescribing habits in order to improve patient outcomes, reduce antimicrobial resistance, and reduce hospital costs. Multiple society-endorsed guidelines and government policies reinforce the importance of ASP implementation. Effective antimicrobial stewardship can impact unique patients, hospitals, and societal antibiotic-resistance burden. The role and subsequent success of these programs has largely been reported in the adult population. Pediatric and neonatal intensive care units present unique challenges for traditional antimicrobial stewardship approaches. The purpose of this review article is to explore the challenges of appropriate antibiotic use in the pediatric and neonatal intensive care units and to summarize strategies ASPs can use to overcome these challenges. These problems include non-specific disease presentations, limited evidence for definitive treatment durations in many pediatric infections, fewer pediatric-trained infectious disease physicians, and applicability of intensive laboratory obtainment, collection, and interpretation. Additionally, many ASP implementation studies evaluating the efficacy of ASPs exclude the PICU and NICU. Areas of focus for pediatric ASPs should likely include appropriate antibiotic initiation, appropriate antibiotic duration, and appropriate antibiotic de-escalation.
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Hu F, Guo SJ, Lu JJ, Hua NX, Song YY, Lin SF, Zhu S. New screening approach to detecting congenital syphilis in China: a retrospective cohort study. Arch Dis Child 2021; 106:231-237. [PMID: 33355158 PMCID: PMC7907569 DOI: 10.1136/archdischild-2020-320549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Diagnosis of congenital syphilis (CS) is not straightforward and can be challenging. This study aimed to evaluate the validity of an algorithm using timing of maternal antisyphilis treatment and titres of non-treponemal antibody as predictors of CS. METHODS Confirmed CS cases and those where CS was excluded were obtained from the Guangzhou Prevention of Mother-to-Child Transmission of syphilis programme between 2011 and 2019. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) using receiver operating characteristics (ROC) in two situations: (1) receiving antisyphilis treatment or no-treatment during pregnancy and (2) initiating treatment before 28 gestational weeks (GWs), initiating after 28 GWs or receiving no treatment for syphilis seropositive women. RESULTS Among 1558 syphilis-exposed children, 39 had confirmed CS. Area under the curve, sensitivity and specificity of maternal non-treponemal titres before treatment and treatment during pregnancy were 0.80, 76.9%, 78.7% and 0.79, 69.2%, 88.7%, respectively, for children with CS. For the algorithm, ROC results showed that PPV and NPV for predicting CS were 37.3% and 96.4% (non-treponemal titres cut-off value 1:8 and no antisyphilis treatment), 9.4% and 100% (non-treponemal titres cut-off value 1:16 and treatment after 28 GWs), 4.2% and 99.5% (non-treponemal titres cut-off value 1:32 and treatment before 28 GWs), respectively. CONCLUSIONS An algorithm using maternal non-treponemal titres and timing of treatment during pregnancy could be an effective strategy to diagnose or rule out CS, especially when the rate of loss to follow-up is high or there are no straightforward diagnostic tools.
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Affiliation(s)
- Fang Hu
- Department of Child Health, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Shuai-Jun Guo
- Centre for Community Child Health, Murdoch Children's Research Institute, Melbourne, Victoria, Australia,Department of Pediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jian-Jun Lu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China,Department of Medical Affairs, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Ning-Xuan Hua
- Department of Child Health, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yan-Yan Song
- Department of Child Health, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Sui-Fang Lin
- Department of Child Health, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Sui Zhu
- Department of Medical Statistics, School of Medicine, Jinan University, Guangzhou, Guangdong, China
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