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Sferra SR, Penikis AB, Guo M, Baschat AA, Mogayzel PJ, Burton VJ, Kunisaki SM. Neurodevelopmental Outcomes in Children After Fetoscopic Endoluminal Tracheal Occlusion for Severe Congenital Diaphragmatic Hernia: Results From a Multidisciplinary Clinic. J Pediatr Surg 2024; 59:1271-1276. [PMID: 38599907 DOI: 10.1016/j.jpedsurg.2024.03.041] [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: 03/12/2024] [Accepted: 03/12/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND We compared early neurodevelopmental morbidity in young children with severe CDH who underwent FETO to those without fetal therapy. METHODS We conducted a prospective study of severe CDH patients undergoing FETO (n = 18) at a single North American center from 2015 to 2021 (NCT02710968). Outpatient survivors (n = 12) were evaluated by a multidisciplinary team and compared to expectantly managed CDH patients. Neurodevelopmental outcomes were assessed using the Capute Scales [Clinical Linguistic and Auditory Milestone Scales (CLAMS) and Cognitive Adaptive Test (CAT)], with a developmental quotient (DQ) < 85 indicative of at-risk for delay. RESULTS At one year, 58% (n = 7) of FETO patients underwent evaluation, with notable concern for language delay (CLAMS median DQ, 80.1 [interquartile range, 67.6-86.7]). FETO scores improved by 24-months, whereas high severity/non-FETO scores declined [CLAMS median DQ (Difference in DQ), 92.3 (+12.2) vs. 77.1 (-13.4), respectively; p = 0.049]. On the initial CAT, FETO patients had concern for visual motor and problem-solving delays, with a median DQ of 81.3 (62.1-89.4). At 24-months, FETO patients had improving scores [Median CAT DQ, 90.8 (+9.5)], whereas high severity/non-FETO [87.5 (-3.0), p = 0.28] had declining scores. CONCLUSION These initial data suggest that FETO is associated with favorable neurodevelopmental outcomes at 24-months compared to severe CDH under expectant management. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Shelby R Sferra
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Annalise B Penikis
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Matthew Guo
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA
| | - Peter J Mogayzel
- Eudowood Division of Pediatric Pulmonary, Department of Pediatrics, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Baltimore, MD 21287, USA
| | - Vera Joanna Burton
- Neurology and Developmental Medicine, Department of Neurology, Johns Hopkins University School of Medicine, 801 N. Broadway Baltimore, MD 21205, USA
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA.
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Sobotka SA, Lynch E, Liao C, Graham RJ, Msall ME. Autism and neurodevelopmental disability risks in children with tracheostomies and ventilators. Pediatr Pulmonol 2024; 59:1380-1387. [PMID: 38426806 DOI: 10.1002/ppul.26921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/31/2024] [Accepted: 02/06/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND/OBJECTIVE Infants who survive prematurity and other critical illnesses and require continued invasive mechanical ventilation (IMV) postdischarge (at home) are at high risk of developmental delays and disabilities. Studies of extremely preterm cohorts (<28-week gestation) demonstrate rates of 25% for intellectual disability (ID) and 7% for autism spectrum disorder (ASD). Rates of ASD and ID in children with IMV are unknown. This study aimed to determine neurodevelopmental disability risk in a cohort of children with postdischarge IMV. DESIGN/METHODS A consecutive series of children with IMV were assessed 1 month, 6 months, and 1 year after discharge. Cognitive, social, and communicative domains were assessed by a Developmental and Behavioral Pediatrician using (1) clinical adaptive test/clinical linguistic and auditory milestone scale (CAT/CLAMS) of the capute scales; (2) pediatric evaluation of disability inventory computer adaptive test (PEDI-CAT); and (3) modified checklist for autism in toddlers, revised (MCHAT-R). Red flag signs and symptoms of ASD using DSM-V criteria were noted. Longitudinal testing was reviewed. Expert consensus impressions of evolving ASD and/or ID were determined. RESULTS Eighteen children were followed for 1 year; at 1 year, the median age (range) was 23 (17-42) months. Children were 44% male, 33% non-Hispanic White, 39% non-Hispanic Black, and 28% Hispanic. Fifteen (83%) children were prematurity survivors. Median (range) developmental quotients (DQs): full-scale DQ 59 (11-86), CAT DQ 66.5 (8-96), and CLAMS DQ 49.5 (13-100). Twelve (67%) children were highly suspicious for ASD and/or evolving ID. CONCLUSIONS/SIGNIFICANCE This cohort of children with at-home IMV demonstrates a higher risk of ASD and ID than prior premature cohorts. Larger investigations with longer follow-up are needed.
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Affiliation(s)
- Sarah A Sobotka
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, The University of Chicago, Chicago, Illinois, USA
| | - Emma Lynch
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, The University of Chicago, Chicago, Illinois, USA
| | - Chuanhong Liao
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois, USA
| | - Robert J Graham
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michael E Msall
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, The University of Chicago, Chicago, Illinois, USA
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Lach LE, Chetta KE, Gregoski MJ, Katikaneni LD. Trends in Preterm Body Composition and Neurodevelopmental Outcomes after Discharge. Neonatology 2023; 120:681-689. [PMID: 37673056 PMCID: PMC10773248 DOI: 10.1159/000532111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/06/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION Body composition, specifically fat-free mass (FFM), of preterm infants is associated with improved neurodevelopmental outcomes. Little is known about body composition of preterm infants after discharge. Preterm body composition was measured by air displacement plethysmography (ADP) at two time points, inpatient (35-40 weeks postmenstrual age [PMA]) and outpatient (48-58 weeks PMA), with neonatal factors and neurodevelopmental testing at 4-6 months corrected age. We hypothesized increased FFM is positively associated with neurodevelopment. METHODS From 2007 to 2011, 510 infants admitted to the Medical University of South Carolina's neonatal intensive care unit underwent ADP. A total of 379 of 510 (74%) had anthropometrics at birth, an ADP scan with FFM, fat mass, fat percent z-scores, and an outpatient neurodevelopmental evaluation (CAT/CLAMS, Peabody Gross Motor). Variables were compared using multivariate analyses for body composition measurements. RESULTS The infants were 32 ± 4.8 weeks gestational age at birth with an average birth weight of 1,697 ± 932 g. Most (56%) infants received maternal milk at discharge. CAT, CLAMS, and gross motor scores had positive correlations with FFM z-scores at inpatient and outpatient ADP (p < 0.05). Receiving maternal milk at discharge was positively associated with cognitive (β = 0.22, p < 0.05) and language scores (β = 0.26, p < 0.05). CONCLUSION Increased FFM is associated with improved cognitive, language, and gross motor testing. Maternal milk was positively associated with language and cognitive scores.
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Affiliation(s)
- Laura E. Lach
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Katherine E. Chetta
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Mathew J. Gregoski
- Department of Public Health Sciences Medical University of South Carolina, Charleston, SC, USA
| | - Lakshmi D. Katikaneni
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
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Sobotka SA, Lynch E, Msall ME, Graham RJ. Early childhood developmental skills of children with tracheostomies and ventilators recently discharged home. Pediatr Pulmonol 2023; 58:853-865. [PMID: 36448249 PMCID: PMC10680148 DOI: 10.1002/ppul.26265] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/03/2022] [Accepted: 11/25/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Infants who survive prematurity and critical illnesses but require ongoing invasive mechanical ventilation (IMV) are at high risk for developmental disabilities. However, their detailed developmental profiles are largely unknown. OBJECTIVE To understand the developmental profiles of a cohort of young children with IMV after hospital-to-home transition. DESIGN/METHODS Developmental testing was completed 1 month after hospital discharge to determine functioning within motor, cognitive, and communicative domains using (1) the Clinical Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS); (2) the Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT); and (3) The Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA-FS). To complement validated testing, semi-structured interviews were conducted with parents to understand perceived influences on neurodevelopment. RESULTS Twenty children were evaluated at median (range) age 11 (5-27) months. Nearly half (45%) were male, 40% non-Hispanic Black, and 25% Hispanic. Sixteen (80%) children were survivors of prematurity. After gestational age correction, median (range) full-scale developmental quotients (DQ) were 69.5 (8-119): CAT DQ 62.5 (3-113) and CLAMS DQ 71.5 (12-125). Parents described that prolonged restriction within the hospital crib away from caregivers, despite hospital therapists, impedes development. Home environments improve development primarily through increased time with parents, but also play outside of the crib. One month after hospital discharge only 10% were receiving early intervention therapies. CONCLUSIONS/SIGNIFICANCE Children with IMV display wide ranges of neurodevelopmental skills with a majority experiencing substantial delays in motor, communicative, and adaptive functioning. The degree and cross-domain challenges highlight the need for targeted and timely therapeutic strategies.
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Affiliation(s)
- Sarah A. Sobotka
- Department of Pediatrics, Section of Developmental and Behavioral Pediatrics, The University of Chicago, Chicago, Illinois, USA
| | - Emma Lynch
- Department of Pediatrics, Section of Developmental and Behavioral Pediatrics, The University of Chicago, Chicago, Illinois, USA
| | - Michael E. Msall
- Department of Pediatrics, Section of Developmental and Behavioral Pediatrics, The University of Chicago, Chicago, Illinois, USA
| | - Robert J. Graham
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
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Modified Ride-on Car Intervention for Children With Profound Intellectual and Multiple Disabilities: A Case Series. Pediatr Phys Ther 2023; 35:277-283. [PMID: 36854116 DOI: 10.1097/pep.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
PURPOSE To describe a pilot clinical case series of a modified ride-on car (MROC) intervention on mobility and alertness for young children with profound intellectual and multiple disabilities (PIMD). METHODS Four young children with PIMD participated in 4 baseline observations and 5 intervention sessions (A-B design). Data collection occurred via video. Assessment of mobility and alertness duration used structured visual analysis. RESULTS Three of the 4 children increased their independent mobility during the intervention sessions. One of the 4 children increased their active alertness during the intervention sessions. CONCLUSIONS This pilot study demonstrates the initial feasibility of an MROC intervention in a clinical setting and outcome measures of mobility and alertness for children with PIMD. This provides support that this population should be considered for power mobility in early childhood. Further, this study used a novel, caregiver-implemented prompting protocol to teach children how to use the MROC.
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Lach LE, Chetta KE, Ruddy-Humphries AL, Ebeling MD, Gregoski MJ, Katikaneni LD. Body Composition and "Catch-Up" Fat Growth in Healthy Small for Gestational Age Preterm Infants and Neurodevelopmental Outcomes. Nutrients 2022; 14:3051. [PMID: 35893903 PMCID: PMC9332383 DOI: 10.3390/nu14153051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/08/2022] [Accepted: 07/22/2022] [Indexed: 11/25/2022] Open
Abstract
To examine the growth and body composition of small for gestational age (SGA) and appropriate for gestational age (AGA) very low birth weight infants (VLBW) and their outpatient neurodevelopmental outcomes. From 2006-2012, VLBW infants (n = 57 of 92) admitted to the Neonatal Intensive Care Unit (NICU) had serial air displacement plethysmography (ADP) scans and were followed as outpatients. Serial developmental testing (CAT/CLAMS, Peabody Gross Motor Scales) and anthropometrics were obtained from n = 37 infants (29 AGA and 8 SGA) and analyzed via repeated measures analyses of variances. The percentage of body fat, percentage of lean mass, and weight gain were statistically significant between SGA and AGA groups at the first ADP assessment. There was no difference between the two groups in outpatient neurodevelopmental testing. Weight gain as "catch-up" body fat accrual occurs by 67 weeks of PMA. This catch-up growth is associated with normal SGA preterm neurodevelopment as compared to AGA preterm infants.
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Affiliation(s)
- Laura E. Lach
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA; (K.E.C.); (A.L.R.-H.); (M.D.E.); (L.D.K.)
| | - Katherine E. Chetta
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA; (K.E.C.); (A.L.R.-H.); (M.D.E.); (L.D.K.)
| | - Amy L. Ruddy-Humphries
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA; (K.E.C.); (A.L.R.-H.); (M.D.E.); (L.D.K.)
| | - Myla D. Ebeling
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA; (K.E.C.); (A.L.R.-H.); (M.D.E.); (L.D.K.)
| | - Mathew J. Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC 29425, USA;
| | - Lakshmi D. Katikaneni
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA; (K.E.C.); (A.L.R.-H.); (M.D.E.); (L.D.K.)
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Dorner RA, Allen MC, Robinson S, Soares BP, Perin J, Ramos E, Gerner G, Burton VJ. Early neurodevelopmental outcome in preterm posthemorrhagic ventricular dilatation and hydrocephalus: Neonatal ICU Network Neurobehavioral Scale and imaging predict 3-6-month motor quotients and Capute Scales. J Neurosurg Pediatr 2020; 25:217-227. [PMID: 31860810 PMCID: PMC7305038 DOI: 10.3171/2019.9.peds19438] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 09/16/2019] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Brain injury remains a serious complication of prematurity. Almost half of infants with severe intraventricular hemorrhage (IVH) develop posthemorrhagic ventricular dilatation (PHVD) and 20% need surgery for posthemorrhagic hydrocephalus (PHH). This population is associated with an increased risk of later neurodevelopmental disability, but there is uncertainty about which radiological and examination features predict later disability. In this study the authors sought to devise and describe a novel combination of neurobehavioral examination and imaging for prediction of neurodevelopmental disability among preterm infants with PHVD and PHH. METHODS The study patients were preterm infants (< 36 weeks gestation) with IVH and PHVD, with or without PHH. Ventricular index (VI), anterior horn width (AHW), thalamooccipital distance (TOD), ventricle/brain (V/B) ratio, and resistive indices (RIs) were recorded on the head ultrasound (HUS) just prior to surgery, or the HUS capturing the worst PHVD when surgery was not indicated. The posterior fossa was assessed with MRI. Neonatal ICU Network Neurobehavioral Scale (NNNS) examinations were performed at term age equivalent for each infant. A neurodevelopmental assessment using the Capute Scales (Capute Cognitive Adaptive Test [CAT] scores and Capute Clinical Linguistic Auditory Milestone Scale [CLAMS] scores) and a motor quotient (MQ) assessment were performed between 3 and 6 months of age corrected for degree of prematurity (corrected age). MQs < 50 reflect moderate to severe delays in early motor milestone attainment, CAT scores < 85 reflect delays in early visual and problem-solving abilities, and CLAMS scores < 85 reflect delays in early language. RESULTS Twenty-one infants underwent assessments that included imaging and NNNS examinations, Capute Scales assessments, and MQs. NNNS nonoptimal reflexes (NOR) and hypertonicity subscores and AHW were associated with MQs < 50: NOR subscore OR 2.46 (95% CI 1.15-37.6, p = 0.034), hypertonicity subscore OR 1.68 (95% CI 1.04-3.78, p = 0.037), and AHW OR 1.13 (95% CI 1.01-1.39, p = 0.041). PVHI, cystic changes, and neurosurgical intervention were associated with CAT scores < 85: PVHI OR 9.2 (95% CI 1.2-73.2, p = 0.037); cystic changes OR 12.0 (95% CI 1.0-141.3, p = 0.048), and neurosurgical intervention OR 11.2 (95% CI 1.0-120.4, p = 0.046). Every 1-SD increase in the NOR subscore was associated with an increase in odds of a CAT score < 85, OR 4.0 (95% CI 1.0-15.0, p = 0.044). Worse NNNS NOR subscores were associated with early language delay: for a 1-SD increase in NOR subscore, there was an increase in the odds of a CLAMS score < 85, OR 19.5 (95% CI 1.3-303, p = 0.034). CONCLUSIONS In former preterm children with severe IVH and PHVD, neonatal neurological examination findings and imaging features are associated with delays at 3-6 months in motor milestones, visual and problem-solving abilities, and language.
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Affiliation(s)
- Rebecca A. Dorner
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine
- Neurosciences Intensive Care Nursery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Marilee C. Allen
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine
- Neurosciences Intensive Care Nursery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Shenandoah Robinson
- Neurosciences Intensive Care Nursery, Johns Hopkins Hospital, Baltimore, Maryland
- Pediatric Neurosurgery, Johns Hopkins University School of Medicine
| | - Bruno P. Soares
- Radiology, University of Vermont Medical Center, Burlington, Vermont
| | - Jamie Perin
- Bloomberg School of Public Health, Biostatistics, Epidemiology, and Data Management Core, Johns Hopkins University, Baltimore, Maryland
| | - Ezequiel Ramos
- Medical Doctorate Program, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Vera Joanna Burton
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, Maryland
- Department of Neurology, Johns Hopkins University School of Medicine
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Granhagen Jungner J, Tiselius E, Wenemark M, Blomgren K, Lützén K, Pergert P. Development and evaluation of the Communication over Language Barriers questionnaire (CoLB-q) in paediatric healthcare. PATIENT EDUCATION AND COUNSELING 2018; 101:1661-1668. [PMID: 29705667 DOI: 10.1016/j.pec.2018.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 04/17/2018] [Accepted: 04/18/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To develop a valid and reliable questionnaire addressing the experiences of healthcare personnel of communicating over language barriers and using interpreters in paediatric healthcare. METHODS A multiple- methods approach to develop and evaluate the questionnaire, including focus groups, cognitive interviews, a pilot test and test-retest. The methods were chosen in accordance with questionnaire development methodology to ensure validity and reliability. RESULTS The development procedure showed that the issues identified were highly relevant to paediatric healthcare personnel and resulted in a valid and reliable Communication over Language Barriers questionnaire (CoLB-q) with 27 questions. CONCLUSION The CoLB-q is perceived as relevant, important and easy to respond to by respondents and has satisfactory validity and reliability. PRACTICE IMPLICATIONS The CoLB-q can be used to map how healthcare personnel overcome language barriers through communication tools and to identify problems encountered in paediatric healthcare. Furthermore, the transparently described process could be used as a guide for developing similar questionnaires.
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Affiliation(s)
- Johanna Granhagen Jungner
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Tomtebodavägen 18 A, Floor 5, SE-171 77 Stockholm, Sweden.
| | - Elisabet Tiselius
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Tomtebodavägen 18 A, Floor 5, SE-171 77 Stockholm, Sweden; Department of Swedish Language and Multilingualism, Institute for Interpreting and Translation Studies, Stockholm University, SE-106 91 Stockholm, Sweden.
| | - Marika Wenemark
- Department of Medicine and Health Sciences, Division of Community Medicine, Linköping University, SE-581 83 Linköping, Sweden; Centre for Organisational Support and Development, Region Östergötland, SE-58185 Linköping, Sweden.
| | - Klas Blomgren
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Tomtebodavägen 18 A, Floor 5, SE-171 77 Stockholm, Sweden; Pediatric Oncology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
| | - Kim Lützén
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Tomtebodavägen 18 A, Floor 5, SE-171 77 Stockholm, Sweden.
| | - Pernilla Pergert
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Tomtebodavägen 18 A, Floor 5, SE-171 77 Stockholm, Sweden; Pediatric Oncology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
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