Acta Pædiatrica ISSN 0803-5253
SHORT COMMUNICATION
Skills retention 3 months after neonatal resuscitation training in a cohort of healthcare workers in Sierra Leone N Conroy ([email protected])1, J Kaiwo1, DA Barr2, L Mitchell3, B Morrissey1, SB Lambert4,5 1.Bo Government Hospital, Bo, Sierra Leone 2.Liverpool School of Tropical Medicine, Liverpool, UK 3.School of Medicine, The University of Queensland, Brisbane, QLD, Australia 4.Queensland Children’s Medical Research Institute, The University of Queensland and Children’s Health Queensland, Brisbane, QLD, Australia 5.Communicable Diseases Unit, Queensland Health, Brisbane, QLD, Australia
Correspondence N Conroy, Bo Government Hospital, Hospital Road, Bo District, Sierra Leone. Tel: +353 862135313 | Email: [email protected] Received 15 August 2014; accepted 19 November 2014. DOI:10.1111/apa.12875
Sierra Leone has the highest neonatal mortality rate in the world, with one in 20 infants not surviving the neonatal period (Approx 50 deaths per 1000 live births) (1). Just over a third (35%) of these newborns die within 24 h of delivery (2). There is evidence that neonatal resuscitation programmes in low-resource settings may reduce neonatal mortality by up to 30% and reduce stillbirth rates (3). However, the ability to perform neonatal resuscitation in these settings is very limited (4). The dominant model of neonatal resuscitation training in Sierra Leone involves delivering one of several stand-alone training courses, with refresher training after 1 or 2 years, although some programmes offer ongoing mentorship after training. There is contrasting evidence on the effectiveness of this type of training, and the most effective mode of delivery, in resource-constrained settings (5). This study aimed to evaluate skills retention amongst healthcare workers 3 months after attending a 1-day Neonatal Basic Life Support (NBLS) course. The NBLS training course was developed locally, with input from local and overseas experts. It was delivered to healthcare workers from Bo Government Hospital and other local healthcare facilities in small groups over a period of 3 weeks in November 2013. The average instructor: student ratio was 1:8. The 1-day course covered neonatal resuscitation protocols based on guidelines published by the International Liaison Committee on Resuscitation (6) and the European Resuscitation Council (7) and adapted for use in the local setting. Resuscitation training involved immediate assessment of the newborn, meconium aspiration, initiation of resuscitation, drying technique, bag and mask ventilation, cardiopulmonary resuscitation, airway manoeuvres, appropriate use of oxygen when available and termination of
resuscitation efforts. A clear protocol for immediate resuscitation was the central theme for the training programme. Advanced airway techniques were not covered, as there is no capacity in Bo district for neonatal ventilation. The use of medication during resuscitation was not taught, as they are not available locally and are not required in the majority of neonatal resuscitations. Guidance on how to recognise neonatal danger signs was also provided, as well as on general newborn care and the management of sepsis, hypoglycaemia and hypothermia. The course was similar in duration and content to others described previously in the literature (8–10). Training was delivered using a mixture of didactic teaching and practical, manikin-based training. There was a particular focus on practical resuscitation training scenarios. Students sat a practical exam immediately upon completion of the course – the primary skills test – where their practical skills were assessed in a simulated resuscitation scenario using a neonatal manikin. Each candidate was given a score out of 10, based on successfully completing a series of steps in the resuscitation process. Candidates were then invited back for a reassessment 12 weeks after completion of the course, for the purpose of internal quality control. During this assessment, they were given the same scenario that was assessed in the first exam and the same marking criteria were used. In both assessments, candidates were examined by one of two instructors, either an experienced physician or an experienced paediatric nurse with specific neonatal training. The Sierra Leone Research Ethics Committee advised that no formal ethics committee approval was required for this study as it was an internal quality assurance review. However, each participant, however, signed a consent form, agreeing that their results could be used in this study.
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 1305–1307
1305
Neonatal resuscitation skills retention
Conroy et al.
The objective of the study was to evaluate resuscitation skills retention immediately and 3 months after attending the training course. The primary measured outcomes were therefore the baseline examination score immediately after completing the training and the 12-week repeat testing score. We compared baseline and repeating testing results using a repeated-measures ANOVA. All statistical analyses were carried out in Medcalcâ v13.1.1 and R v3.1.0 (MedCalc Software, Ostend, Belgium). The training was attended by 48 midwives, maternal and child health aides, paediatric nurses and theatre nurses from Bo Government Hospital and surrounding clinics and 34 (71%) attended for retesting 12 weeks after course completion. Candidates who re-attended for repeat testing did not differ significantly at baseline from those that did not re-attend (Table 1). Table 1 Baseline characteristics of those who attended for retesting versus those who did not amongst NBLS attendees
Number of participants Female, n (%) Midwives, n (%) Baseline skills test score, median (IQR)
Returned for retesting
Did not return for retesting
34
14
30 (88.2%) 12 (35.3%) 90 (80 to 100)
11 (78.6%) 6 (42.9%) 85 (80 to 90)
*Two-tailed p-value from chi-squared test. **Two-tailed p-value from Mann–Whitney test. IQR, Interquartile range; n, number.
p-value for difference between groups
0.68* 0.87* 0.41**
The training course was delivered on two separate days in November 2013. Immediately upon completion of the course (baseline), the median score for the primary skills test was 90% (IQR 80 to 100%); 12 weeks later, the median had reduced to 55% (IQR 30 to 70%) (Fig. 1). This reduction in score was statistically significant when assessed by repeated-measures ANOVA: F(1,33) = 74.3, p < 0.001. The mean reduction in scores from baseline to week 12 was slightly less for the 12 healthcare workers with regular midwifery duties than those without ( 30% versus 35%), but no significant interaction effect was found when regular midwifery duties was included in a factorial repeated-measures ANOVA: F(1,32) = 0.21, p = 0.651. Furthermore, the baseline score did not show correlation with magnitude of score reduction: R2 = 0.00; Spearman’s coefficient of rank correlation, rho = 0.06. Scores were not different between cohorts trained on different days (data not shown). After attending a Newborn Basic Life Support training course in Sierra Leone, students performed very well in a structured competency assessment. However, their skills had deteriorated when they were reassessed 12 weeks after the training. The reduction in scores was clinically meaningful and statistically significant. The skills that had deteriorated most at the 12-week retest were identifying the need for resuscitation, effective bag and mask ventilation and the ability to initiate cardiopulmonary resuscitation when appropriate. Students in the study only received the stand-alone training with no ongoing on the job training or mentoring after the course, which is one of the dominant models of neonatal resuscitation training in Sierra Leone and many resource-constrained settings.
Figure 1 Distribution of scores by job cadre and time point amongst healthcare workers attending NBLS training in Bo District, Sierra Leone.
1306
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 1305–1307
Neonatal resuscitation skills retention
Conroy et al.
Interestingly, we found that, despite regular involvement with neonatal resuscitation, those students who had regular midwifery duties did not have a statistically significant difference in score compared with the other cadres of health worker that attended the training. Their mean baseline and 12-week scores, as well as their score differences, were not significantly different to healthcare workers who were not midwives. These results are at odds with other data showing better simulated performance in candidates who are exposed to more than five resuscitations per month compared to those who are exposed to fewer real-life resuscitations (11). However, these results are in keeping with data from previous local research, which showed that only 14% of healthcare workers in obstetric referral centres in Bo district were able to perform adequate neonatal resuscitation in simulated scenarios (4). Our findings suggest that stand-alone training, without ongoing mentoring, may not be suitable for low-resource settings, although it should be noted that the performance of students during real-life resuscitations was not examined as part of this study. The optimal model for delivering newborn resuscitation training in low-resource settings is still unclear, with variable results being reported when using different methodological approaches (9,12–15). It is not only in low-resource settings that difficulties with skills retention have been identified, with the same issue identified after neonatal life support training in Europe (11). However, the combination of a very high neonatal mortality rate in Sierra Leone and the limited neonatal skills within the health workforce means that this is a knowledge gap that needs to be addressed urgently by locally appropriate training programmes. It is important that neonatal training in the country is delivered within the context of a broader strategy, focusing on improving maternal and neonatal health with an emphasis on ongoing education and training. Further data are required to determine the best way to deliver locally developed neonatal care training courses in low-resource settings. The strengths of this study lie in the fact that it provides a 3-month follow-up period and provides previously lacking data on front-line neonatal skills in a nonacademic hospital within a high-burden lowincome country. Our study has limitations. There was no pretraining testing performed and the endpoints focused on performance in simulated resuscitation scenarios, rather than in real-life resuscitations. Once locally relevant and sustainable training models are developed, a randomised controlled trial would be the best method to assess how to best deliver training within high-burden settings. Information on optimal instructor: student ratios, course duration, course content and delivery method is required, as well as their effect on neonatal survival.
ACKNOWLEDGEMENTS We would like to thank Dr Robert Ware, School of Population Heath, The University of Queensland, Australia, for his advice regarding statistical methods.
FUNDING No specific funding was received for this work. However, SBL receives fellowship support from the National Health and Medical Research Council and from the Children’s Health Foundation, Queensland.
References 1. UN Inter-agency Group for Child Mortality Estimation (IGME). Levels and trends in child mortality: report 2013. New York, NY: UNICEF, 2013. 2. Save the Children. Surviving the first day. State of the world’s mothers 2013. London: Save the Children, 2013. 3. Lee AC, Cousens S, Wall SN, Niermeyer S, Darmstadt GL, Carlo WA, et al. Neonatal resuscitation and immediate newborn assessment and stimulation for the prevention of neonatal deaths: a systematic review, meta-analysis and Delphi estimation of mortality effect. BMC Public Health 2011; 11: S12. 4. Conroy N, Jalloh CS, Mitchell L, Solanki A, Seedat A, Lambert SB. Neonatal resuscitation skills amongst healthcare workers in Bo district, Sierra Leone. Resuscitation 2014; 85: e31–2. 5. Conroy N, Morrissey B, Wolman Y. Reducing neonatal mortality in resource-poor settings: what works? J Neonatal Biol 2014; 3: 139. 6. Perlman JM, Wyllie J, Kattwinkel J, Atkins DL, Chameides L, Goldsmith JP, et al. Part 11: neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2010; 122: S516–38. 7. Richmond S, Wyllie J. European resuscitation council guidelines for resuscitation 2010 section 7, Resuscitation of babies at birth. Resuscitation 2010; 81: 1389–99. 8. Opiyo N, Were F, Govedi F, Fegan G, Wasunna A, English M. Effect of newborn resuscitation training on health worker practices in Pumwani hospital, Kenya. PLoS ONE 2008; 3: e1599. 9. Hole MK, Olmsted K, Kiromera A, Chamberlain L. A neonatal resuscitation curriculum in Malawi, Africa: did it change inhospital mortality? Int J Pediatr 2012; 2012: 408689. 10. Bookman L, Engmann C, Srofenyoh E, Enweronu-Laryea C, Owen M, Randolph G, et al. Educational impact of a hospitalbased neonatal resuscitation program in Ghana. Resuscitation 2010; 81: 1180–2. 11. Mosley CM, Shaw BN. A longitudinal cohort study to investigate the retention of knowledge and skills following attendance on the Newborn Life support course. Arch Dis Child 2013; 98: 582–6. 12. Msemo G, Massawe A, Mmbando D, Rusibamayila N, Manji K, Kidanto HL, et al. Newborn mortality and fresh stillbirth rates in Tanzania after helping babies breathe training. Pediatrics 2013; 131: e353. 13. Carlo WA, McClure EM, Chomba E, Chakraborty H, Hartwell T, Harris H, et al. Newborn care training of midwives and neonatal and perinatal mortality rates in a developing country. Pediatrics 2010; 126: e1064–71. 14. Matendo R, Engmann C, Ditekemena J, Gado J, Tshefu A, Kinoshita R, et al. Reduced perinatal mortality following enhanced training of birth attendants in the Democratic Republic of Congo: a time-dependent effect. BMC Med 2011; 9: 93. 15. Musafili A, Essen B, Baribwira C, Rukundo A, Persson LA. Evaluating Helping Babies Breathe: training for healthcare workers at hospitals in Rwanda. Acta Paediatr 2013; 102: e34–8.
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 1305–1307
1307
SHORT COMMUNICATION
Skills retention 3 months after neonatal resuscitation training in a cohort of healthcare workers in Sierra Leone N Conroy ([email protected])1, J Kaiwo1, DA Barr2, L Mitchell3, B Morrissey1, SB Lambert4,5 1.Bo Government Hospital, Bo, Sierra Leone 2.Liverpool School of Tropical Medicine, Liverpool, UK 3.School of Medicine, The University of Queensland, Brisbane, QLD, Australia 4.Queensland Children’s Medical Research Institute, The University of Queensland and Children’s Health Queensland, Brisbane, QLD, Australia 5.Communicable Diseases Unit, Queensland Health, Brisbane, QLD, Australia
Correspondence N Conroy, Bo Government Hospital, Hospital Road, Bo District, Sierra Leone. Tel: +353 862135313 | Email: [email protected] Received 15 August 2014; accepted 19 November 2014. DOI:10.1111/apa.12875
Sierra Leone has the highest neonatal mortality rate in the world, with one in 20 infants not surviving the neonatal period (Approx 50 deaths per 1000 live births) (1). Just over a third (35%) of these newborns die within 24 h of delivery (2). There is evidence that neonatal resuscitation programmes in low-resource settings may reduce neonatal mortality by up to 30% and reduce stillbirth rates (3). However, the ability to perform neonatal resuscitation in these settings is very limited (4). The dominant model of neonatal resuscitation training in Sierra Leone involves delivering one of several stand-alone training courses, with refresher training after 1 or 2 years, although some programmes offer ongoing mentorship after training. There is contrasting evidence on the effectiveness of this type of training, and the most effective mode of delivery, in resource-constrained settings (5). This study aimed to evaluate skills retention amongst healthcare workers 3 months after attending a 1-day Neonatal Basic Life Support (NBLS) course. The NBLS training course was developed locally, with input from local and overseas experts. It was delivered to healthcare workers from Bo Government Hospital and other local healthcare facilities in small groups over a period of 3 weeks in November 2013. The average instructor: student ratio was 1:8. The 1-day course covered neonatal resuscitation protocols based on guidelines published by the International Liaison Committee on Resuscitation (6) and the European Resuscitation Council (7) and adapted for use in the local setting. Resuscitation training involved immediate assessment of the newborn, meconium aspiration, initiation of resuscitation, drying technique, bag and mask ventilation, cardiopulmonary resuscitation, airway manoeuvres, appropriate use of oxygen when available and termination of
resuscitation efforts. A clear protocol for immediate resuscitation was the central theme for the training programme. Advanced airway techniques were not covered, as there is no capacity in Bo district for neonatal ventilation. The use of medication during resuscitation was not taught, as they are not available locally and are not required in the majority of neonatal resuscitations. Guidance on how to recognise neonatal danger signs was also provided, as well as on general newborn care and the management of sepsis, hypoglycaemia and hypothermia. The course was similar in duration and content to others described previously in the literature (8–10). Training was delivered using a mixture of didactic teaching and practical, manikin-based training. There was a particular focus on practical resuscitation training scenarios. Students sat a practical exam immediately upon completion of the course – the primary skills test – where their practical skills were assessed in a simulated resuscitation scenario using a neonatal manikin. Each candidate was given a score out of 10, based on successfully completing a series of steps in the resuscitation process. Candidates were then invited back for a reassessment 12 weeks after completion of the course, for the purpose of internal quality control. During this assessment, they were given the same scenario that was assessed in the first exam and the same marking criteria were used. In both assessments, candidates were examined by one of two instructors, either an experienced physician or an experienced paediatric nurse with specific neonatal training. The Sierra Leone Research Ethics Committee advised that no formal ethics committee approval was required for this study as it was an internal quality assurance review. However, each participant, however, signed a consent form, agreeing that their results could be used in this study.
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 1305–1307
1305
Neonatal resuscitation skills retention
Conroy et al.
The objective of the study was to evaluate resuscitation skills retention immediately and 3 months after attending the training course. The primary measured outcomes were therefore the baseline examination score immediately after completing the training and the 12-week repeat testing score. We compared baseline and repeating testing results using a repeated-measures ANOVA. All statistical analyses were carried out in Medcalcâ v13.1.1 and R v3.1.0 (MedCalc Software, Ostend, Belgium). The training was attended by 48 midwives, maternal and child health aides, paediatric nurses and theatre nurses from Bo Government Hospital and surrounding clinics and 34 (71%) attended for retesting 12 weeks after course completion. Candidates who re-attended for repeat testing did not differ significantly at baseline from those that did not re-attend (Table 1). Table 1 Baseline characteristics of those who attended for retesting versus those who did not amongst NBLS attendees
Number of participants Female, n (%) Midwives, n (%) Baseline skills test score, median (IQR)
Returned for retesting
Did not return for retesting
34
14
30 (88.2%) 12 (35.3%) 90 (80 to 100)
11 (78.6%) 6 (42.9%) 85 (80 to 90)
*Two-tailed p-value from chi-squared test. **Two-tailed p-value from Mann–Whitney test. IQR, Interquartile range; n, number.
p-value for difference between groups
0.68* 0.87* 0.41**
The training course was delivered on two separate days in November 2013. Immediately upon completion of the course (baseline), the median score for the primary skills test was 90% (IQR 80 to 100%); 12 weeks later, the median had reduced to 55% (IQR 30 to 70%) (Fig. 1). This reduction in score was statistically significant when assessed by repeated-measures ANOVA: F(1,33) = 74.3, p < 0.001. The mean reduction in scores from baseline to week 12 was slightly less for the 12 healthcare workers with regular midwifery duties than those without ( 30% versus 35%), but no significant interaction effect was found when regular midwifery duties was included in a factorial repeated-measures ANOVA: F(1,32) = 0.21, p = 0.651. Furthermore, the baseline score did not show correlation with magnitude of score reduction: R2 = 0.00; Spearman’s coefficient of rank correlation, rho = 0.06. Scores were not different between cohorts trained on different days (data not shown). After attending a Newborn Basic Life Support training course in Sierra Leone, students performed very well in a structured competency assessment. However, their skills had deteriorated when they were reassessed 12 weeks after the training. The reduction in scores was clinically meaningful and statistically significant. The skills that had deteriorated most at the 12-week retest were identifying the need for resuscitation, effective bag and mask ventilation and the ability to initiate cardiopulmonary resuscitation when appropriate. Students in the study only received the stand-alone training with no ongoing on the job training or mentoring after the course, which is one of the dominant models of neonatal resuscitation training in Sierra Leone and many resource-constrained settings.
Figure 1 Distribution of scores by job cadre and time point amongst healthcare workers attending NBLS training in Bo District, Sierra Leone.
1306
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 1305–1307
Neonatal resuscitation skills retention
Conroy et al.
Interestingly, we found that, despite regular involvement with neonatal resuscitation, those students who had regular midwifery duties did not have a statistically significant difference in score compared with the other cadres of health worker that attended the training. Their mean baseline and 12-week scores, as well as their score differences, were not significantly different to healthcare workers who were not midwives. These results are at odds with other data showing better simulated performance in candidates who are exposed to more than five resuscitations per month compared to those who are exposed to fewer real-life resuscitations (11). However, these results are in keeping with data from previous local research, which showed that only 14% of healthcare workers in obstetric referral centres in Bo district were able to perform adequate neonatal resuscitation in simulated scenarios (4). Our findings suggest that stand-alone training, without ongoing mentoring, may not be suitable for low-resource settings, although it should be noted that the performance of students during real-life resuscitations was not examined as part of this study. The optimal model for delivering newborn resuscitation training in low-resource settings is still unclear, with variable results being reported when using different methodological approaches (9,12–15). It is not only in low-resource settings that difficulties with skills retention have been identified, with the same issue identified after neonatal life support training in Europe (11). However, the combination of a very high neonatal mortality rate in Sierra Leone and the limited neonatal skills within the health workforce means that this is a knowledge gap that needs to be addressed urgently by locally appropriate training programmes. It is important that neonatal training in the country is delivered within the context of a broader strategy, focusing on improving maternal and neonatal health with an emphasis on ongoing education and training. Further data are required to determine the best way to deliver locally developed neonatal care training courses in low-resource settings. The strengths of this study lie in the fact that it provides a 3-month follow-up period and provides previously lacking data on front-line neonatal skills in a nonacademic hospital within a high-burden lowincome country. Our study has limitations. There was no pretraining testing performed and the endpoints focused on performance in simulated resuscitation scenarios, rather than in real-life resuscitations. Once locally relevant and sustainable training models are developed, a randomised controlled trial would be the best method to assess how to best deliver training within high-burden settings. Information on optimal instructor: student ratios, course duration, course content and delivery method is required, as well as their effect on neonatal survival.
ACKNOWLEDGEMENTS We would like to thank Dr Robert Ware, School of Population Heath, The University of Queensland, Australia, for his advice regarding statistical methods.
FUNDING No specific funding was received for this work. However, SBL receives fellowship support from the National Health and Medical Research Council and from the Children’s Health Foundation, Queensland.
References 1. UN Inter-agency Group for Child Mortality Estimation (IGME). Levels and trends in child mortality: report 2013. New York, NY: UNICEF, 2013. 2. Save the Children. Surviving the first day. State of the world’s mothers 2013. London: Save the Children, 2013. 3. Lee AC, Cousens S, Wall SN, Niermeyer S, Darmstadt GL, Carlo WA, et al. Neonatal resuscitation and immediate newborn assessment and stimulation for the prevention of neonatal deaths: a systematic review, meta-analysis and Delphi estimation of mortality effect. BMC Public Health 2011; 11: S12. 4. Conroy N, Jalloh CS, Mitchell L, Solanki A, Seedat A, Lambert SB. Neonatal resuscitation skills amongst healthcare workers in Bo district, Sierra Leone. Resuscitation 2014; 85: e31–2. 5. Conroy N, Morrissey B, Wolman Y. Reducing neonatal mortality in resource-poor settings: what works? J Neonatal Biol 2014; 3: 139. 6. Perlman JM, Wyllie J, Kattwinkel J, Atkins DL, Chameides L, Goldsmith JP, et al. Part 11: neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2010; 122: S516–38. 7. Richmond S, Wyllie J. European resuscitation council guidelines for resuscitation 2010 section 7, Resuscitation of babies at birth. Resuscitation 2010; 81: 1389–99. 8. Opiyo N, Were F, Govedi F, Fegan G, Wasunna A, English M. Effect of newborn resuscitation training on health worker practices in Pumwani hospital, Kenya. PLoS ONE 2008; 3: e1599. 9. Hole MK, Olmsted K, Kiromera A, Chamberlain L. A neonatal resuscitation curriculum in Malawi, Africa: did it change inhospital mortality? Int J Pediatr 2012; 2012: 408689. 10. Bookman L, Engmann C, Srofenyoh E, Enweronu-Laryea C, Owen M, Randolph G, et al. Educational impact of a hospitalbased neonatal resuscitation program in Ghana. Resuscitation 2010; 81: 1180–2. 11. Mosley CM, Shaw BN. A longitudinal cohort study to investigate the retention of knowledge and skills following attendance on the Newborn Life support course. Arch Dis Child 2013; 98: 582–6. 12. Msemo G, Massawe A, Mmbando D, Rusibamayila N, Manji K, Kidanto HL, et al. Newborn mortality and fresh stillbirth rates in Tanzania after helping babies breathe training. Pediatrics 2013; 131: e353. 13. Carlo WA, McClure EM, Chomba E, Chakraborty H, Hartwell T, Harris H, et al. Newborn care training of midwives and neonatal and perinatal mortality rates in a developing country. Pediatrics 2010; 126: e1064–71. 14. Matendo R, Engmann C, Ditekemena J, Gado J, Tshefu A, Kinoshita R, et al. Reduced perinatal mortality following enhanced training of birth attendants in the Democratic Republic of Congo: a time-dependent effect. BMC Med 2011; 9: 93. 15. Musafili A, Essen B, Baribwira C, Rukundo A, Persson LA. Evaluating Helping Babies Breathe: training for healthcare workers at hospitals in Rwanda. Acta Paediatr 2013; 102: e34–8.
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 1305–1307
1307
