Patrick Ip

Nurturing care: promoting early childhood development.

The UN Sustainable Development Goals provide a historic opportunity to implement interventions, at scale, to promote early childhood development. Although the evidence base for the importance of early childhood development has grown, the research is distributed across sectors, populations, and settings, with diversity noted in both scope and focus. We provide a comprehensive updated analysis of early childhood development interventions across the five sectors of health, nutrition, education, child protection, and social protection. Our review concludes that to make interventions successful, smart, and sustainable, they need to be implemented as multi-sectoral intervention packages anchored in nurturing care. The recommendations emphasise that intervention packages should be applied at developmentally appropriate times during the life course, target multiple risks, and build on existing delivery platforms for feasibility of scale-up. While interventions will continue to improve with the growth of developmental science, the evidence now strongly suggests that parents, caregivers, and families need to be supported in providing nurturing care and protection in order for young children to achieve their developmental potential.

Spinal Muscular Atrophy: Survival Pattern and Functional Status

Objective. Spinal muscular atrophy (SMA) is common. The prevalence of SMA in southern Chinese is 1 in 53 000. The clinical course is variable. The traditional classification of SMA includes age of onset, age of death, achievement of motor milestones, and ambulatory status as criteria. There was a lack of inclusion of the best lifetime functional status of any child with SMA. With the advances in medical care, the life expectancy and ambulatory status of patients with SMA have improved. The objective of this study was to assess the survival pattern, ambulatory status, and functional status of children with SMA. Methods. Patients with SMA were recruited from the neuromuscular clinic of the Duchess of Kent Childrens Hospital, which is a university-affiliated hospital, and the Families of SMA in Hong Kong. By September 2002, 102 SMA cases had been registered in the Duchess of Kent Childrens Hospital neuromuscular clinic and Families of SMA registry, and 83 patients were analyzed. Among them, 39 were recruited for the administration of Functional Independence Measure for Children (WeeFIM), an assessment tool for functional status that has been previously validated by us for Chinese children. The diagnosis of SMA was made from clinical history, serum muscle enzyme, electromyography, muscle biopsy, and, recently, by molecular studies. In Hong Kong, molecular tests of the survivor motor neuron gene was available since 1995. A total of 36 in our cohort of 83 patients had the diagnosis confirmed with molecular analyses. We adopted the classification of SMA from previous studies in which the criteria were based on the International SMA consortium (1992) with modifications according to the 59th European Neuromuscular Center International Workshops. As only SMA patients with childhood onset were studied, we did not include any type IV patients in our study. Parents were interviewed and records were reviewed for demographic and clinical data, including age of onset, gender, family history, motor milestones, disease progression, loss of motor function, and involvement of respiratory or bulbar muscles. We define the age of disease onset as the age in which the first abnormalities were obvious from the medical records or from the descriptions of the parents about the first signs of weakness, eg, age of achievement of certain motor milestones or loss of functions. For the ambulatory status, we define “being ambulatory” as having the ability to walk for 100 meters, either with assistance such as calipers or walkers or without assistance. Actuarial survival curves were obtained by using the Kaplan-Meier method for calculating survival probabilities and probabilities of remaining ambulatory. The parents or the chief caregivers were interviewed for functional status using WeeFIM at the last registered date in September 2002. The WeeFIM consists of 3 domains: 1) self-care, 2) mobility, and 3) cognition. The self-care domain consists of 8 items, namely eating, grooming, bathing, dressing (upper body), dressing (lower body), toileting, and bladder and bowel management. The mobility domain consists of 5 items: transfer from chair or wheelchair, transfer to toilet, transfer to tub or shower, walking/wheelchair/crawling distance, and moving up and down stairs. The cognition domain assesses comprehension, expression, social interaction, problem solving, and memory. A scoring scale from 1 to 7 was used (1 = total assistance, 2 = maximal assistance, 3 = moderate assistance, 4 = minimal contact assistance, 5 = supervision, 6 = modified independence, and 7 = complete independence). The maximum total WeeFIM score is 126, and the maximum score for self-care, mobility, and cognition are 56, 35, and 35, respectively. Results. For type I SMA (n = 22), the survival probabilities at 1, 2, 4, 10, and 20 years were 50%, 40%, 30%, 30%, and 30%, respectively. For type II SMA (n = 26), the survival probabilities at 1, 2, 4, 10, and 20 years were 100%, 100%, 100%, 92%, and 92%, respectively. Sixteen of the SMA I patients and 4 of the SMA II patients died of cardiorespiratory failure. The 5 surviving SMA I patients all were ventilator dependent. All SMA III patients were surviving at the time of study. The probability of remaining ambulatory at 2, 4, 10, and 20 years after onset was 100%, 100%, 81%, and 50% for type IIIa (age of onset <3 years) and 100%, 100%, 84%, and 68% for type IIIb (age of onset between 3 and 30 years), respectively. The interval between disease onset and inability to walk was 15.0 ± 10.9 years (mean ± standard deviation) and 21.2 ± 11.7 years for patients with SMA IIIa and IIIb, respectively. Only 39 patients participated in the WeeFIM interview as 20 had already died at the time of study and 24 refused participation. No difference could be found in the age of onset, gender, or types of SMA between those who participated (n = 39) and those who did not (n = 24). The mean total WeeFIM quotients were 24% for SMA type 1, 57% for SMA type 11, 75% for SMA type IIIa, and 78% for SMA type IIIb. For the self-care domain, 100% SMA type I and 73% SMA type II patients required assistance, whereas 55% and 63% of SMA types IIIa and IIIb patients achieved functional independence. Bathing and dressing (upper and lower body) were items with which most SMA children required help or supervision. For the mobility domain, assistance was needed in >90% of SMA types I, II, and IIIa and in 63% of SMA type IIIb patients. Stair management was the major obstacle for independence in achieving mobility for all types of SMA. For the cognition domain, performance was the best among the 3 domains, and 60% of SMA type II, 78% of SMA type IIIa, and 90% of SMA type IIIb patients achieved functional independence. However, except for SMA type IIIb, a significant proportion of patients still need assistance or supervision in the area of problem solving. Statistically significant differences were found in the WeeFIM scores between type I and type II and between type IIIa and IIIb patients. However, no significant difference could be observed between type II and type IIIa SMA patients in the overall WeeFIM scores or performance in any of the 3 domains. Conclusion. We found that there was improvement in survival in SMA patients as compared with other studies. Assistance or supervision was needed for the majority of SMA patients for both mobility and self-care domains. With improvement in survival as a result of medical advances, assessment of the most current or the best-ever functional status at a designated age might be an important criterion for classification of SMA.

Mercury Exposure in Children With Autistic Spectrum Disorder: Case-Control Study

Although mercury has been proven to be a neurotoxicant, there is a lack of data to evaluate the causal relationship between mercury and autism. We aim to see if there is increased mercury exposure in children with autistic spectrum disorder. We performed a cross-sectional cohort study over a 5-month period in 2000 to compare the hair and blood mercury levels of children with autistic spectrum disorder (n = 82; mean age 7.2 years) and a control group of normal children (n = 55; mean age 7.8 years). There was no difference in the mean mercury levels. The mean blood mercury levels of the autistic and control groups were 19.53 and 17.68 nmol/L, respectively (P = .15), and the mean hair mercury levels of the autistic and control groups were 2.26 and 2.07 ppm, respectively (P = .79). Thus, the results from our cohort study with similar environmental mercury exposure indicate that there is no causal relationship between mercury as an environmental neurotoxin and autism. (J Child Neurol 2004;19:431-434).

Peritoneal dialysis after surgery for congenital heart disease in infants and young children

BACKGROUND We determined the risk factors for peritoneal dialysis (PD) in young children undergoing open heart surgery and, in those patients requiring PD, factors associated with prolonged PD and mortality. METHODS The clinical records of 182 children, aged 3 years or younger, who had undergone open heart surgery during a 2-year period were reviewed. Demographic data, preoperative risk factors, intraoperative variables, and postoperative complications were compared between patients requiring PD and those who did not, and between survivors and nonsurvivors of PD. RESULTS Of the 182 patients, 31 (17%) required PD. Patients requiring PD were lighter and more likely to have required preoperative ventilation; had undergone more complex surgery requiring longer bypass and circulatory arrest; and had experienced a pulmonary hypertensive crisis (p < 0.01). Logistic regression identified circulatory arrest (relative risk, 9.4; p = 0.002), cardiopulmonary bypass duration (relative risk, 1.02; p = 0.028), and low cardiac output syndrome (relative risk, 12.9; p < 0.0001) as significant determinants. Peritoneal dialysis was effective in achieving negative fluid balance, although serum urea and creatinine levels remained static. Prolonged PD was associated with younger age, higher preoperative serum creatinine, higher postoperative oxygen requirement, postoperative pulmonary hypertensive crisis, and low cardiac output syndrome (p < 0.05). When compared with survivors (n = 22), nonsurvivors (n = 9) were more likely to have had syndrome disorders and required preoperative ventilation and higher postoperative ventilatory settings (p < 0.05). CONCLUSIONS Risk factors for PD in young children undergoing open heart surgery are circulatory arrest, cardiopulmonary bypass duration, and low cardiac output syndrome. The preoperative and postoperative cardiopulmonary status has a significant bearing on PD duration and patient survival.

Risk factors prolonging ventilation in young children after cardiac surgery: Impact of noninfectious pulmonary complications.

Objective To determine risk factors for prolonged ventilation after cardiac surgery in young children and assess the impact of noninfectious pulmonary complications on ventilatory duration. Design Retrospective case series analysis. Setting A tertiary pediatric cardiac center. Patients Clinical records of 222 consecutive children aged ≤3 yrs undergoing cardiac surgery for congenital heart disease were reviewed. Fifteen patients, consisting of six premature babies and nine who died within 72 hrs of surgery, were excluded. Measurements and Main Results The demographic data, preoperative risk factors, surgical procedures performed, intraoperative variables, and postoperative complications of the remaining 207 children were reviewed. Univariate analysis was performed to compare patients who required prolonged ventilation (>72 hrs) to those who could be extubated at ≤72 hrs, and multivariate analyses were performed to identify significant determinants on ventilatory duration and impact of noninfectious complications. Of the 182 patients undergoing open heart surgery, 45 (25%) required prolonged ventilation for a median of 8 days. The latter were significantly younger in age and lighter in weight and were more likely to have Down syndrome, preoperative pulmonary hypertension and ventilatory support, undergone more complex surgery requiring longer bypass and circulatory arrest time, postoperative cardiovascular and pulmonary complications, and extubation failure (all p values <.01). Of the 25 patients who had closed heart surgery, five (20%) required prolonged ventilation for a median of 14 days. The latter were more likely to require preoperative ventilation, have undergone more complex surgery, had postoperative cardiovascular and pulmonary complications, and had extubation failure (all p values <.05). Cox proportional hazard regression identified body weight (p < .001), Down syndrome (p = .02), need for preoperative ventilation (p < .001), complexity of surgery (p < .001), cardiovascular complications (p < .001), and infective (p < .001) and noninfective (p < .001) pulmonary complications to be significant factors that determined the ventilatory duration. Noninfectious pulmonary complications occurred in 31.9% (58/182) and 20% (5/25) of patients after open and closed heart surgery, respectively. In the absence of other risk factors, the median time to extubation was similar between patients with and without noninfectious complications (1 vs. 0.8 day). However, in the presence of other risk factors, noninfectious pulmonary complications prolonged the median time to extubation from 8 to 18 days. Logistic regression identified Down syndrome (p = .005), preoperative ventilation (p = .001), complexity of surgery (p = .006), and bypass time (p = .005) as risk factors for development of noninfectious pulmonary complications. Conclusions Noninfectious pulmonary complications that occurred commonly after cardiac surgery in young children prolong ventilatory duration only in the presence of other risk factors, with which it acts in a synergistic fashion.

Methylphenidate and the Risk of Trauma

BACKGROUND AND OBJECTIVE: Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) are prone to sustaining trauma that requires emergency department (ED) admission. Methylphenidate (MPH) can reduce ADHD symptoms and may thus theoretically reduce the risk of trauma-related ED admission, but previous studies do not make this association clear. This study examines this association. METHODS: A total of 17 381 patients aged 6 to 19 years who received MPH prescriptions were identified by using the Clinical Data Analysis & Reporting System (2001–2013). Using a self-controlled case series study design, the relative incidence of trauma-related ED admissions was compared with periods of patient exposure and nonexposure to MPH. RESULTS: Among 17 381 patients prescribed MPH, 4934 had at least 1 trauma-related ED admission. The rate of trauma-related ED admission was lower during exposed periods compared with nonexposed periods (incidence rate ratio [IRR]: 0.91 [95% confidence interval (CI): 0.86–0.97]). The findings were similar only when the incident trauma episode was assessed (IRR: 0.89 [95% CI: 0.82–0.96]). A similar protective association was found in both genders. In validation analysis using nontrauma-related ED admissions as a negative control outcome, no statistically significant association was found (IRR: 0.99 [95% CI: 0.95–1.02]). All sensitivity analyses demonstrated consistent results. CONCLUSIONS: This study supports the hypothesis that MPH is associated with a reduced risk of trauma-related ED admission in children and adolescents. A similar protective association was found in both male and female patients. This protective association should be considered in clinical practice.

Environmental mercury exposure in children: South China's experience

Background : Environmental mercury levels significantly increased in the past decades following its increase in industrial applications. In spite of an increasing concern on the potential harmful effects of mercury on children, there is no reported data for the Chinese population. The relationship between dietary habit and environmental mercury exposure in Chinese children was studied.

Antenatal risk factors for postnatal depression: a prospective study of chinese women at maternal and child health centres

BackgroundRisk factors for postnatal depression (PND) are under-explored in the Chinese populations. There is increasing recognition of the importance of identifying predictive factors during the antenatal period for PND. The present study aimed to identify the risk factors for postnatal depression in a community cohort of Chinese women with special focus on the antenatal risk factors.MethodsEight hundred and five Chinese women were interviewed during their third trimester of pregnancy and at around 2 months postnatally. Putative risk factors for PND were collected and the diagnosis of PND was confirmed by the Structured Clinical Interview for DSM-IV Axis I Disorders. The 2-month postnatal depression status was used as the dependent variable for univariate and multivariate analyses against putative risk factors.ResultsMarital dissatisfaction (Relative Risk = 8.27), dissatisfied relationship with mother-in-law (Relative Risk = 3.93), antenatal depressive symptomatology (Relative Risk = 3.90), and anxiety-prone personality (Relative Risk = 2.14) predicted PND in Chinese women independently.ConclusionsChinese women tend to keep their own feelings and emotions and it is important to monitor Chinese pregnant women with these predictive risk factors so that PND can be identified early.

Neonatal convulsion revealing maternal hyperparathyroidism: an unusual case of late neonatal hypoparathyroidism

Abstract. Neonatal convulsion is a very alarming manifestation of underlying sinister problem. As an important cause, neonatal hypocalcemia usually occurs soon after birth and reflects abnormal maternal calcium regulation. We report an unusual case of late neonatal hypocalcemia presented with intractable seizures after two-month-old. Further investigations revealed maternal hyperparathyroidism secondary to parathyroid adenoma, which was missed during antenatal checkup. High index of suspicion is necessary in early detection and prompt treatment of neonatal hypocalcemia. Screening of maternal calcium level is mandatory in unexplained late neonatal hypocalcemia as mother with primary hyperparathyroidism could be asymptomatic and first manifest as late-onset neonatal convulsion. Early detection and appropriate intervention could avoid serious maternal and fetal morbidity.

How people react to Zika virus outbreaks on Twitter? A computational content analysis

Zika-related Twitter incidence peaked after the World Health Organization declared an emergency. Five themes were identified from Zika-related Twitter content: (1) societal impact of the outbreak; (2) government, public and private sector, and general public responses to the outbreak; (3) pregnancy and microcephaly: negative health consequences related to pregnant women and babies; (4) transmission routes; and (5) case reports. User-generated contents sites were preferred direct information channels rather than those of the government authorities.