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Writing a Bibliography: APA FormatEmail

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Below are standard formats and examples for basic bibliographic information recommended by the

American Psychological Association (APA). For more information on the APA format,

see http://www.apastyle.org.

Basics

Your list of works cited should begin at the end of the paper on a new page with the centered

title, References. Alphabetize the entries in your list by the author's last name, using the letter-by-letter

system (ignore spaces and other punctuation.) Only the initials of the first and middle names are given. If

the author's name is unknown, alphabetize by the title, ignoring any A, An, or The.

For dates, spell out the names of months in the text of your paper, but abbreviate them in the list of works

cited, except for May, June, and July. Use either the day-month-year style (22 July 1999) or the month-

day-year style (July 22, 1999) and be consistent. With the month-day-year style, be sure to add a comma

after the year unless another punctuation mark goes there.

Underlining or Italics?

When reports were written on typewriters, the names of publications were underlined because most

typewriters had no way to print italics. If you write a bibliography by hand, you should still underline the

names of publications. But, if you use a computer, then publication names should be in italics as they are

below. Always check with your instructor regarding their preference of using italics or underlining. Our

examples use italics.

Hanging Indentation

All APA citations should use hanging indents, that is, the first line of an entry should be flush left, and the

second and subsequent lines should be indented 1/2".

Capitalization, Abbreviation, and Punctuation

The APA guidelines specify using sentence-style capitalization for the titles of books or articles, so you

should capitalize only the first word of a title and subtitle. The exceptions to this rule would be periodical

titles and proper names in a title which should still be capitalized. The periodical title is run in title case,

and is followed by the volume number which, with the title, is also italicized.

If there is more than one author, use an ampersand (&) before the name of the last author. If there are

more than six authors, list only the first one and use et al. for the rest.

Place the date of publication in parentheses immediately after the name of the author. Place a period

after the closing parenthesis. Do not italicize, underline, or put quotes around the titles of shorter works

within longer works.

Format Examples

Books

Format:Author's last name, first initial. (Publication date). Book title. Additional information. City of publication: Publishing company.

Examples:

Allen, T. (1974). Vanishing wildlife of North America. Washington, D.C.: National Geographic Society.

Boorstin, D. (1992). The creators: A history of the heroes of the imagination. New York: Random House.

Nicol, A. M., & Pexman, P. M. (1999). Presenting your findings: A practical guide for creating tables.

Washington, DC: American Psychological Association.

Searles, B., & Last, M. (1979). A reader's guide to science fiction. New York: Facts on File, Inc.

Toomer, J. (1988). Cane. Ed. Darwin T. Turner. New York: Norton.

Encyclopedia & Dictionary

Format:Author's last name, first initial. (Date). Title of Article. Title of Encyclopedia (Volume, pages). City of publication: Publishing company.

Examples:

Bergmann, P. G. (1993). Relativity. In The new encyclopedia britannica (Vol. 26, pp. 501-508). Chicago:

Encyclopedia Britannica.

Merriam-Webster's collegiate dictionary (10th ed.). (1993). Springfield, MA: Merriam-Webster.

Pettingill, O. S., Jr. (1980). Falcon and Falconry. World book encyclopedia. (pp. 150-155). Chicago: World

Book.

Tobias, R. (1991). Thurber, James. Encyclopedia americana. (p. 600). New York: Scholastic Library

Publishing.

Magazine & Newspaper Articles

Format:Author's last name, first initial. (Publication date). Article title. Periodical title, volume number(issue number if available), inclusive pages. 

Note: Do not enclose the title in quotation marks. Put a period after the title. If a periodical includes a volume number, italicize it and then give the page range (in regular type) without "pp." If the periodical does not use volume numbers, as in newspapers, use p. or pp. for page numbers. Note: Unlike other periodicals, p. or pp. precedes page numbers for a newspaper reference in APA style.

Examples:

Harlow, H. F. (1983). Fundamentals for preparing psychology journal articles. Journal of Comparative and

Physiological Psychology, 55, 893-896.

Henry, W. A., III. (1990, April 9). Making the grade in today's schools. Time, 135, 28-31.

Kalette, D. (1986, July 21). California town counts town to big quake. USA Today, 9, p. A1.

Kanfer, S. (1986, July 21). Heard any good books lately? Time, 113, 71-72.

Trillin, C. (1993, February 15). Culture shopping. New Yorker, pp. 48-51.

Website or Webpage

Format:Online periodical:Author's name. (Date of publication). Title of article. Title of Periodical, volume number, Retrieved month day, year, from full URL

Online document:

Author's name. (Date of publication). Title of work. Retrieved month day, year, from full URL 

Note: When citing Internet sources, refer to the specific website document. If a document is undated, use

"n.d." (for no date) immediately after the document title. Break a lengthy URL that goes to another line

after a slash or before a period. Continually check your references to online documents. There is no

period following a URL. 

Note: If you cannot find some of this information, cite what is available.

Examples:

Devitt, T. (2001, August 2). Lightning injures four at music festival. The Why? Files. Retrieved January 23,

2002, from http://whyfiles.org/137lightning/index.html

Dove, R. (1998). Lady freedom among us. The Electronic Text Center. Retrieved June 19, 1998, from

Alderman Library, University of Virginia website: http://etext.lib.virginia.edu/subjects/afam.html 

Note: If a document is contained within a large and complex website (such as that for a university or a

government agency), identify the host organization and the relevant program or department before giving

the URL for the document itself. Precede the URL with a colon.

Fredrickson, B. L. (2000, March 7). Cultivating positive emotions to optimize health and well-

being. Prevention & Treatment, 3, Article 0001a. Retrieved November 20, 2000, from

http://journals.apa.org/prevention/volume3/pre0030001a.html

GVU's 8th WWW user survey. (n.d.). Retrieved August 8, 2000, from

http://www.cc.gatech.edu/gvu/usersurveys/survey1997-10/

Health Canada. (2002, February). The safety of genetically modified food crops. Retrieved March 22,

2005, from http://www.hc-sc.gc.ca/english/protection/biologics_genetics/gen_mod_foods/genmodebk.html

Hilts, P. J. (1999, February 16). In forecasting their emotions, most people flunk out. New York Times.

Retrieved November 21, 2000, from http://www.nytimes.com

Sample

Sample Bibliography: APA Reference List Format

Booth, S.A. (January 1999). High-Drain Alkaline AA-Batteries. Popular Electronics, 62, 58.

Dell, R. M., and Rand, D.A.J. (2001). Understanding batteries. Cambridge, UK: The Royal Society of

Chemistry.

Devitt, T. (2001, August 2). Lightning injures four at music festival. The Why? Files. Retrieved from

http://whyfiles.org/137lightning/index.html

Dove, R. (1998). Lady freedom among us. The University of Virginia Alderman Library Electronic Text

Center. Retrieved from     http://etext.lib.virginia.edu/subjects/afam.html

Fredrickson, B. L. (2000, March 7). Cultivating positive emotions to optimize health and well-

being. Prevention & Treatment, 3, Article 0001a. Retrieved from

http://journals.apa.org/prevention/volume3/pre0030001a.html

Health Canada. (2002, February). The Safety of Genetically Modified Food Crops. Retrieved from

    http://www.hc-sc.gc.ca/english/protection/biologics_genetics/gen_mod_foods/genmodebk.html

Hilts, P. J. (1999, February 16). In Forecasting Their Emotions, Most People Flunk Out. New York

Times. Retrieved from http://www.nytimes.com

General APA Guidelines

Your essay should be typed, double-spaced on standard-sized paper (8.5" x 11") with 1" margins on all sides. You should use a clear font that is highly readable. APA recommends using 12 pt. Times New Roman font.

Include a page header  (also known as the "running head") at the top of every page. To create a page header/running head, insert page numbers flush right. Then type "TITLE OF YOUR PAPER" in the header flush left using all capital letters. The running head is a shortened version of your paper's title and cannot exceed 50 characters including spacing and punctuation.

Major Paper Sections

Your essay should include four major sections: the Title Page, Abstract, Main Body, andReferences.

Title Page

The title page should contain the title of the paper, the author's name, and the institutional affiliation. Include the page header (described above) flush left with the page number flush right at the top of the page. Please note that on the title page, your page header/running head should look like this:

Running head: TITLE OF YOUR PAPER

Pages after the title page should have a running head that looks like this:

TITLE OF YOUR PAPER

After consulting with publication specialists at the APA, OWL staff learned that the APA 6th edition, first printing sample papers have incorrect examples of Running heads on pages after the title page. This link will take you to the APA site where you can find a complete list of all the errors in the APA's 6th edition style guide.

Type your title in upper and lowercase letters centered in the upper half of the page. APA recommends that your title be no more than 12 words in length and that it should not contain abbreviations or words that serve no purpose. Your title may take up one or two lines. All text on the title page, and throughout your paper, should be double-spaced.

Beneath the title, type the author's name: first name, middle initial(s), and last name. Do not use titles (Dr.) or degrees (PhD).

Beneath the author's name, type the institutional affiliation, which should indicate the location where the author(s) conducted the research.

APA Citation Style

APA citation style refers to the rules and conventions established by the

American Psychological Association for documenting sources used in a

research paper. APA style requires both in-text citations and a reference list.

For every in-text citation there should be a full citation in the reference list

and vice versa.

The examples of APA styles and formats listed on this page include many of

the most common types of sources used in academic research. For additional

examples and more detailed information about APA citation style, refer to

the Publication Manual of the American Psychological Association and theAPA

Style Guide to Electronic References.

Also, for automatic generation of citations in appropriate citation style, use a

bibliographic citation management program such as Refworks or EndNote.

You can find more information on this in ourCitation Management page.

Reference Citations in Text

In APA style, in-text citations are placed within sentences and paragraphs so

that it is clear what information is being quoted or paraphrased and whose

information is being cited.

Examples:

Works by a single author

The last name of the author and the year of publication are inserted in the

text at the appropriate point.

from theory on bounded rationality (Simon, 1945)

If the name of the author or the date appear as part of the narrative, cite

only missing information in parentheses.

Simon (1945) posited that

Works by multiple authors

When a work has two authors, always cite both names every time the

reference occurs in the text. In parenthetical material join the names with an

ampersand (&).

as has been shown (Leiter & Maslach, 1998)

In the narrative text, join the names with the word "and."

as Leiter and Maslach (1998) demonstrated

When a work has three, four, or five authors, cite all authors the first time

the reference occurs.

Kahneman, Knetsch, and Thaler (1991) found

In all subsequent citations per paragraph, include only the surname of the

first author followed by "et al." (Latin for "and others") and the year of

publication.

Kahneman et al. (1991) found

Works by associations, corporations, government agencies, etc.

The names of groups that serve as authors (corporate authors) are usually

written out each time they appear in a text reference.

(National Institute of Mental Health [NIMH], 2007)

When appropriate, the names of some corporate authors are spelled out in

the first reference and abbreviated in all subsequent citations. The general

rule for abbreviating in this manner is to supply enough information in the

text citation for a reader to locate its source in the Reference List without

difficulty.

(NIMH, 2007)

Works with no author

When a work has no author, use the first two or three words of the work's

title (omitting any initial articles) as your text reference, capitalizing each

word. Place the title in quotation marks if it refers to an article, chapter of a

book, or Web page. Italicize the title if it refers to a book, periodical,

brochure, or report.

on climate change ("Climate and Weather," 1997)

Guide to Agricultural Meteorological Practices (1981)

Anonymous authors should be listed as such followed by a comma and the

date.

on climate change (Anonymous, 2008)

Specific parts of a source

To cite a specific part of a source (always necessary for quotations), include

the page, chapter, etc. (with appropriate abbreviations) in the in-text

citation.

(Stigter & Das, 1981, p. 96)

De Waal (1996) overstated the case when he asserted that "we seem to

be reaching ... from the hands of philosophers" (p. 218).

If page numbers are not included in electronic sources (such as Web-based

journals), provide the paragraph number preceded by the abbreviation

"para." or the heading and following paragraph.

(Mönnich & Spiering, 2008, para. 9)

Reference List

References cited in the text of a research paper must appear in a Reference

List or bibliography. This list provides the information necessary to identify

and retrieve each source.

Order: Entries should be arranged in alphabetical order by authors'

last names. Sources without authors are arranged alphabetically by

title within the same list.

Authors: Write out the last name and initials for all authors of a

particular work. Use an ampersand (&) instead of the word "and" when

listing multiple authors of a single work. e.g. Smith, J. D., & Jones, M.

Titles: Capitalize only the first word of a title or subtitle, and any

proper names that are part of a title.

Pagination: Use the abbreviation p. or pp. to designate page numbers

of articles from periodicals that do not use volume numbers, especially

newspapers. These abbreviations are also used to designate pages in

encyclopedia articles and chapters from edited books.

Indentation*: The first line of the entry is flush with the left margin,

and all subsequent lines are indented (5 to 7 spaces) to form a

"hanging indent".

Underlining vs. Italics*: It is appropriate to use italics instead of

underlining for titles of books and journals.

Two additional pieces of information should be included for works accessed

online.

Internet Address**: A stable Internet address should be included and

should direct the reader as close as possible to the actual work. If the

work has a digital object identifier (DOI), use this. If there is no DOI or

similar handle, use a stable URL. If the URL is not stable, as is often the

case with online newspapers and some subscription-based databases,

use the home page of the site you retrieved the work from.

Date: If the work is a finalized version published and dated, as in the

case of a journal article, the date within the main body of the citation is

enough. However, if the work is not dated and/or is subject to change,

as in the case of an online encyclopedia article, include the date that

you retrieved the information.

* The APA has special formatting standards for the use of indentation and

italics in manuscripts or papers that will be typeset or submitted for official

publication. For more detailed information on these publication standards,

refer to the Publication Manual of the American Psychological Association, or

consult with your instructors or editors to determine their style preferences.

** See the APA Style Guide to Electronic References for information on how

to format URLs that take up more than one line.

Examples:

Articles in journals, magazines, and newspapers

References to periodical articles must include the following elements:

author(s), date of publication, article title, journal title, volume number, issue

number (if applicable), and page numbers.

Journal article, one author, accessed online

Ku, G. (2008). Learning to de-escalate: The effects of regret in

escalation of commitment. Organizational Behavior and Human

Decision Processes, 105(2), 221-232.

doi:10.1016/j.obhdp.2007.08.002

Journal article, two authors, accessed online

Sanchez, D., & King-Toler, E. (2007). Addressing disparities

consultation and outreach strategies for university

settings. Consulting Psychology Journal: Practice and

Research, 59(4), 286-295. doi:10.1037/1065- 9293.59.4.286

Journal article, more than two authors, accessed online

Van Vugt, M., Hogan, R., & Kaiser, R. B. (2008). Leadership,

followership, and evolution: Some lessons from the past. American

Psychologist, 63(3), 182-196. doi:10.1037/0003-066X.63.3.182

Article from an Internet-only journal

Hirtle, P. B. (2008, July-August). Copyright renewal, copyright

restoration, and the difficulty of determining copyright

status. D-Lib Magazine, 14(7/8). doi:10.1045/july2008-hirtle

Journal article from a subscription database (no DOI)

Colvin, G. (2008, July 21). Information worth

billions. Fortune, 158(2), 73-79. Retrieved from Business Source

Complete, EBSCO. Retrieved fromhttp://search.ebscohost.com

Magazine article, in print

Kluger, J. (2008, January 28). Why we love. Time, 171(4), 54-60.

Newspaper article, no author, in print

As prices surge, Thailand pitches OPEC-style rice cartel. (2008, May

5). The Wall Street Journal, p. A9.

Newspaper article, multiple authors, discontinuous pages, in print

Delaney, K. J., Karnitschnig, M., & Guth, R. A. (2008, May 5).

Microsoft ends pursuit of Yahoo, reassesses its online

options. The Wall Street Journal, pp. A1, A12.

Books

References to an entire book must include the following elements: author(s)

or editor(s), date of publication, title, place of publication, and the name of

the publisher.

No Author or editor, in print

Merriam-Webster's collegiate dictionary (11th ed.). (2003).

Springfield, MA: Merriam- Webster.

One author, in print

Kidder, T. (1981). The soul of a new machine. Boston, MA: Little,

Brown & Company.

Two authors, in print

Frank, R. H., & Bernanke, B. (2007). Principles of macro-

economics (3rd ed.). Boston, MA: McGraw-Hill/Irwin.

Corporate author, author as publisher, accessed online

Australian Bureau of Statistics. (2000). Tasmanian year book

2000 (No. 1301.6). Canberra, Australian Capital Territory:

Author. Retrieved

fro

mhttp://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/CA25687

10006989...$File/13016_2000.pdf

Edited book

Gibbs, J. T., & Huang, L. N. (Eds.). (2001). Children of color:

Psychological interventions with culturally diverse youth. San

Francisco, CA: Jossey-Bass.

Dissertations

References for dissertations should include the following elements: author,

date of publication, title, and institution (if you accessed the manuscript copy

from the university collections). If there is a UMI number or a database

accession number, include it at the end of the citation.

Dissertation, accessed online

Young, R. F. (2007). Crossing boundaries in urban ecology: Pathways

to sustainable cities (Doctoral dissertation). Available from

ProQuest Dissertations & Theses database. (UMI No. 327681)

Essays or chapters in edited books

References to an essay or chapter in an edited book must include the

following elements: essay or chapter authors, date of publication, essay or

chapter title, book editor(s), book title, essay or chapter page numbers, place

of publication, and the name of the publisher.

One author

Labajo, J. (2003). Body and voice: The construction of gender in

flamenco. In T. Magrini (Ed.), Music and gender: perspectives

from the Mediterranean (pp. 67-86). Chicago, IL: University of

Chicago Press.

Two editors

Hammond, K. R., & Adelman, L. (1986). Science, values, and human

judgment. In H. R. Arkes & K. R. Hammond (Eds.), Judgement and

decision making: An interdisciplinary reader (pp. 127-143).

Cambridge, England: Cambridge University Press.

Encyclopedias or dictionaries and entries in an encyclopedia

References for encyclopedias must include the following elements: author(s)

or editor(s), date of publication, title, place of publication, and the name of

the publisher. For sources accessed online, include the retrieval date as the

entry may be edited over time.

Encyclopedia set or dictionary

Sadie, S., & Tyrrell, J. (Eds.). (2002). The new Grove dictionary of

music and musicians (2nd ed., Vols. 1-29). New York, NY: Grove.

Article from an online encyclopedia

Containerization. (2008). In Encyclopædia Britannica. Retrieved May

6, 2008, fromhttp://search.eb.com

Encyclopedia article

Kinni, T. B. (2004). Disney, Walt (1901-1966): Founder of the Walt

Disney Company. In Encyclopedia of Leadership (Vol. 1, pp. 345-

349). Thousand Oaks, CA: Sage Publications.

Research reports and papers

References to a report must include the following elements: author(s), date

of publication, title, place of publication, and name of publisher. If the issuing

organization assigned a number (e.g., report number, contract number, or

monograph number) to the report, give that number in parentheses

immediately after the title. If it was accessed online, include the URL.

Government report, accessed online

U.S. Department of Health and Human Services. (2005). Medicaid drug

price comparisons: Average manufacturer price to published

prices (OIG publication No. OEI-05-05- 00240). Washington, DC:

Author. Retrieved fromhttp://www.oig.hhs.gov/oei/reports/oei-05-

05-00240.pdf

Government reports, GPO publisher, accessed online

Congressional Budget Office. (2008). Effects of gasoline prices on

driving behavior and vehicle markets: A CBO study (CBO

Publication No. 2883). Washington, DC: U.S. Government Printing

Office. Retrieved fromhttp://www.cbo.gov/ftpdocs/88xx/doc8893/01-

14-GasolinePrices.pdf

Technical and/or research reports, accessed online

Deming, D., & Dynarski, S. (2008). The lengthening of

childhood (NBER Working Paper 14124). Cambridge, MA: National

Bureau of Economic Research. Retrieved July 21, 2008,

from http://www.nber.org/papers/w14124

Document available on university program or department site

Victor, N. M. (2008). Gazprom: Gas giant under strain. Retrieved

from Stanford University, Program on Energy and Sustainable

Development Web

site

:http://pesd.stanford.edu/publications/gazprom_gas_giant_under_st

rain/

Audio-visual media

References to audio-visual media must include the following elements: name

and function of the primary contributors (e.g., producer, director), date, title,

the medium in brackets, location or place of production, and name of the

distributor. If the medium is indicated as part of the retrieval ID, brackets are

not needed.

Videocassette/DVD

Achbar, M. (Director/Producer), Abbott, J. (Director), Bakan, J.

(Writer), & Simpson, B. (Producer) (2004). The corporation [DVD].

Canada: Big Picture Media Corporation.

Audio recording

Nhat Hanh, T. (Speaker). (1998). Mindful living: a collection of

teachings on love, mindfulness, and meditation [Cassette

Recording]. Boulder, CO: Sounds True Audio.

Motion picture

Gilbert, B. (Producer), & Higgins, C. (Screenwriter/Director).

(1980). Nine to five[Motion Picture]. United States: Twentieth

Century Fox.

Television broadcast

Anderson, R., & Morgan, C. (Producers). (2008, June 20). 60

Minutes [Television broadcast]. Washington, DC: CBS News.

Television show from a series

Whedon, J. (Director/Writer). (1999, December 14). Hush [Television

series episode]. In Whedon, J., Berman, G., Gallin, S., Kuzui,

F., & Kuzui, K. (Executive Producers), Buffy the Vampire Slayer.

Burbank, CA: Warner Bros..

Music recording

Jackson, M. (1982). Beat it. On Thriller [CD]. New York, NY: Sony

Music.

Undated Web site content, blogs, and data

For content that does not easily fit into categories such as journal papers,

books, and reports, keep in mind the goal of a citation is to give the reader a

clear path to the source material. For electronic and online materials, include

stable URL or database name. Include the author, title, and date published

when available. For undated materials, include the date the resource was

accessed.

Blog entry

Arrington, M. (2008, August 5). The viral video guy gets $1 million

in funding. Message posted to http://www.techcrunch.com

Professional Web site

National Renewable Energy Laboratory. (2008). Biofuels. Retrieved

May 6, 2008, fromhttp://www.nrel.gov/learning/re_biofuels.html

Data set from a database

Bloomberg L.P. (2008). Return on capital for Hewitt Packard 12/31/90

to 09/30/08. Retrieved Dec. 3, 2008, from Bloomberg database.

Central Statistics Office of the Republic of Botswana. (2008). Gross

domestic product per capita 06/01/1994 to

06/01/2008 [statistics]. Available from CEIC Data database.

Entire Web site

When citing an entire Web site (and not a specific document on that site), no

Reference List entry is required if the address for the site is cited in the text

of your paper.

Witchcraft In Europe and America is a site that presents the full

text of many essential works in the literature of witchcraft and

demonology (http://www.witchcraft.psmedia.com/).

For more detailed information on APA citation style such as information on

articles in press, journal special issues and supplements, translations, et

cetera, see the Publication Manual of the American Psychological

Association and the APA Style Guide to Electronic References.

Other citation guides and useful Web sites:

American Psychological Association's Web site

Purdue University Online Writing Lab's APA Formatting and Style Guide

Diana Hacker's Research and Documentation Online

Landmark's Son of Citation Machine

merican Psychological Association (APA) Style Guide

Examples below are based on the Publication manual of the American

Psychological Association , 6th ed., located at BF76.7 P83 2010 Info.

Commons Ref.

(Earlier editions may be available in the Main Stacks for checkout under the

same call number.)

Note the specific punctuation, indentation, italicizing and abbreviation.

Alphabetize the list of citations by author.

Please note that in APA style, all lines after the first are indented 5 spaces

or 1/2 inch.

Examples

Book with one author

Book with an editor

Journal articles

Newspaper article

Online article

Lecture

Interview

Web page

Email

More examples & in-text citations

Book with one authorAPA

Author's last name, First and Second Initial. (Year). Title italic. Publication          location*: Publishing company.example:Townsend, R. M. (1993). The medieval village economy. Princeton, NJ:           Princeton University Press.*Note: For U.S. cities, give first place of publication listed, including city and 2-letter postal abbreviations for states (unless state is already included in publisher's name). For non-U.S. cities, give city and country unabbreviated; also include province for Canadian cities.

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Book with an editorAPA

Editor's last name, First and Second Initial. (Ed.). (Year). Title italic.          Publication location*: Publishing company.example:McRae, M. W. (Ed.). (1993). The literature of science: Perspectives on           popular science writing. Athens: University of Georgia Press.*Note: For U.S. cities, give first place of publication listed, including city and 2-letter state postal abbreviations (unless state is already included in publisher's name). For non-U.S. cities, give city and country unabbreviated; also include province for Canadian cities.

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Journal article - one authorAPA

Author's last name, First and Second Initial. (Year). Article title. Journal            title, volume number(issue number*), page numbers.example:Yeh, M. (1996). The "cult of poetry" in contemporary China. Journal of           Asian Studies, 55(2), 51-80.*Note: Issue numbers are only given if each issue begins with page 1; if issues use continuous pagination through the entire volume, give only the volume number.

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Journal article - 3 authorsAPA

Author's last name, First and Second Initial., Author’s last name, First and           Second Initial., & Author’s last name, First and Second Initial.          (Year). Article title. Journal title, volume number(issue          number*), page numbers.example:White, S., Winzelberg, A., & Norlin, J. (1992). Laughter and stress.           Humor, 5, 43-355.*Note: Issue numbers are only given if each issue begins with page 1; if issues use continuous pagination through the entire volume, give only the volume number.

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Newspaper articleAPA

Author's last name, First and Second Initial. (Year, Month Date). Article          title. Newspaper title, volume and/or issue number (if applicable),          pp. page numbers.example:Taylor, P. (1993, December 27). Keyboard grief: Coping with computer-            caused injuries. Globe and Mail, pp. A1, A4.

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Online journal article(For examples of other electronic resources, see the sites listed below or refer to the Publication Manual.) APA

Include the original publication information:Author's last name, First and Second Initial. (Year). Article title. Journal title,            volume(issue number, if not continuously paginated), page numbers.example:Borsari, B., & Carey, K. B. (2000). Effects of a brief motivational intervention          with college student drinkers. Journal of Consulting and Clinical           Psychology, 68, 728-733.If the article has a DOI (digital object identifier) assigned, include it at the end. If there is no DOI, provide the homepage of the journal, preceded by "Retrieved from". Database information is not needed unless the article is difficult to locate; for example, those archived online only in JSTOR or ERIC. Include date of retrieval only if the source is likely to change.Author's last name, First and Second Initial. (Year). Article title. Journal title,            volume, page numbers. Retrieved from [journal homepage URL] OR

            DOIexamples:Davis, C., & Strachan, S. (2001). Elite female athletes with eating disorders:            A study of psychopathological characteristics. Journal of Sport &             Exercise Psychology, 23(3), 245-253. Retrieved from            http://hk.humankinetics.com/jsep/Vardar, E., Vardar, S. A. & Kurt, C. (2007). Anxiety of young female athletes            with disordered eating behaviors. Eating Behaviors, 8, 143-147.            doi:10.1016/j.eatbeh.2006.03.002Clausen, J. A. (1967). The organism and socialization. Journal of Health             and Social Behavior, 8, 243-252. Retrieved from JSTOR.

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LectureAPA

Lector's last name, First and Second Initial. (Year, Month). Lecture title.          Symposium Coordinator's First and Second Initial and Last name          (Coordinator's position) (if applicable), Symposium title. Symposium          conducted at the meeting of Sponsoring Organization name,          Location.example:Atwood, M. (1993, December). Silencing the scream. Boundaries of the           Imagination Forum. Symposium conducted at the meeting of the          MLA Convention, Toronto, Ontario, Canada.

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InterviewAPA

According to the APA Publication Manual, because a personal, unpublished interview consists of unrecoverable data, there is no need to cite it in the reference list. Cite personal communications in text only.

example:

K. W. Schaie (personal communication, November 18, 1993)

Note that published interviews are cited accordingly if they appear as journal articles, newspaper articles, television programs, radio programs, or film

productions.

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Web pageAPA

Author’s last name, First and Second initial. (Year, Month Day). Title of page. Retrieved from URL

Sometimes the author may be the sponsor of the webpage. If there is no author, put the title first, followed by the date. If a month and day aren't given, just use the year. If there's no date at all, use n.d.

example:Arizona Athletics. (2015, June 4). Wildcats collect academic accolades. Retrieved from          http://www.arizonawildcats.com/ViewArticle.dbml?DB_OEM_ID=30700&ATCLID=210131390Call of Duty zombies. (n.d.). Retrieved from http://www.callofdutyzombies.com/

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EmailAPA

Electronic mail is considered a form of personal communication, therefore it is not necessary to cite email in the reference list. Cite email in the text only.

example:

T. Danford (personal communication, March 28, 1997).

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More examples & in-text citationsAPA

APA Formatting and Style Guide (OWL - Online Writing Lab, Purdue University): Excellent guidelines for formatting papers (including a sample paper), in-text citations and references lists, with lots of examples.APA Style Guide (Ohio State University): Includes examples for both reference lists and in-text citations.

APA Citation Style (Cornell University): Includes guidelines and examples for in-text citations and reference lists.APA Format (6th Edition, 2009) examples (University of Minnesota): Crib sheet.From the APA website:

References According to the Vancouver Style for MichenerThe Vancouver Style is formally known as Recommendations for the Conduct,

Reporting, Editing and Publication of Scholarly Work in Medical Journals (ICMJE

Recommendations). It was developed in Vancouver in 1978 by editors of medical

journals and well over 1,000 medical journals (including ICMJE members BMJ, CMAJ,

JAMA & NEJM) use this style. This user guide explains how to cite references in

Vancouver Style, both within the text of a paper and in a reference list, and gives

examples of commonly used types of references.

ICMJE Recommendations has many optional areas. This guide has been created for

The Michener Institute and may differ from styles at other educational institutes and

those required by individual journals.

Citations in the Text:

Placement of citations: In-text citation numbers should be placed after the relevant part

of a sentence. The original Vancouver Style documents do not discuss placement of the

in-text citation in regards to punctuation, so it is acceptable to place it before or after the

period. Be consistent.

References are numbered consecutively in the order they are first mentioned. Place

each reference number in parentheses throughout the text, tables, and legends. If the

same reference is used again, re-use the original number. (See number 3 in the box

below.)

Tables are numbered consecutively. Supply a brief title for each table and give each

column a short heading. Be sure that the table is mentioned in the text. If the data is

taken from another source, include the source in the list of references at the end of the

paper. Place explanatory matter in a note, not in the heading.

Personal communication used as a reference should be avoided, unless it provides

essential information not available from a public source. These can be emails, personal

interviews, telephone conversations, class notes, class handouts that are not posted,

etc. Do not include them in the reference list as they are not recoverable by others;

instead cite the name of the person and date of communication in parentheses in the

text. (See the John Doe example below.)

Internet sources may, in time, be deleted, changed, or moved, so it is a good idea to

keep a hard copy for your records. Also, take care to critically evaluate the reliability of

the information.

Example

Recently, the health sciences community has reduced the bias and imprecision of

traditional literature summaries through the development of rigorous criteria for both

literature overviews (1-3) and practice guidelines (4,5). Even when recommendations

come from such rigorous approaches, however, “it is important to differentiate between

those based on weak vs. strong evidence” (6). Recommendations based on inadequate

evidence often require reversal when sufficient data become available, (John Doe, April

1, 2002) while timely implementation of recommendations based on strong evidence

can save lives (3).

On the References Page:

The last page of your paper is entitled References. References are single spaced, with

double-spacing between references.

Numbering: List all references in order by number, not alphabetically. Each reference is

listed once only, since the same number is used throughout the paper.

Authors: List each author’s last name followed by a space and then initials without any

periods; there is a comma and space between authors and a period at the end of the last

author. If the number of authors exceeds six, give the first six followed by “et al.” (see

example 3 on next page). For edited books, place the editors’ names in the author

position and follow the last editor with a comma and the word editor (or editors). For

edited books with chapters written by individual authors, list the authors of the chapter

first, then the chapter title, followed by “In:”, the editors’ names, and the book title (see

example 7).

Title: Capitalize the first letter of the first word in the title. The rest of the title is in lower-

case, with the exception of proper names. Do not underline the title; do not use italics. If

there is an edition for a book, it appears after the title, abbreviated and followed by a

period, for example: 3rd ed.

Publication information: Books: After the title (and edition if applicable), place a

period and space, then enter the city. If the city is not well known or there could be

confusion, enter the postal abbreviation for the state (U.S.) or province (Canada), or

enter the country (elsewhere) of publication, followed by a colon. Give the name of the

publisher as it appears in the publication followed by a semicolon. If the author is also

the publisher, use part of the name as the publisher, e.g., The Association for publisher if

the author is Canadian Medical Association. Give the year of publication followed by a

period. If no date of publication can be found, but the publication contains a date of

copyright, use the date of copyright preceded by the letter “c”, e.g. c2015.

Publication information: Journals: List the abbreviated journal title, place a period and

a space, year, (and abbreviated month and day if applicable), semi-colon, volume, issue

number in parentheses, colon, page range, and a period. For example, Brain Res.

2002;935(1-2):40-6. (The issue number may be omitted if the journal is paginated

continuously through the volume.)

To find the journal title abbreviation, go to Medline’s Journals Database and search by

journal title. If the title is not found, abbreviate according to the style used for similar titles

in Medline.

Pages: For journals, the entire page range of an article is given, not the specific page on

which the information was found; usage is 124-7 (pages 124 to 127) or 215-22 (pages

215 to 222). For books, no page numbers are given, with two exceptions: the page

number of a dictionary entry is included (see example 10), as well as the page range of

a chapter with its own author (see example 7).

Information specific to online sources  In general, include the same information as

you would for print material and then add retrieval information so others can locate the

sources.

o Place the word Internet in square brackets after the book title or abbreviated

journal title (see examples 2, 8, 9).

o Indicate date of retrieval, preceded by the word “cited”, in square brackets after

the date of publication (see example 2).

o Add retrieval information at the end of the citation using the full URL. There is no

punctuation at the end of the URL unless it ends with a slash, in which case a

period is added (see example 9).

o If a DOI exists, it is optional to add it after the retrieval information (see example

3).

o Include a short note after the URL if special access information is required (see

example 12).

See below for reference examples.

For more information on style and lists of examples, consult:

Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly

Work in Medical Journals (ICMJE Recommendations)

ICMJE Recommendations – Sample References

Citing Medicine, 2 nd   ed.

Note: Bolded headings are for the purposes of this document only; they would

not appear on an actual reference page.

References

Journal article, up to 6 personal author(s):

1. Al-Habian A, Harikumar PE, Stocker CJ, Langlands K, Selway JL. Histochemical and

immunohistochemical evaluation of mouse skin histology: comparison of fixation with

neutral buffered formalin and alcoholic formalin. J Histotechnol. 2014 Dec;37(4):115-24.

Electronic journal article:

2. Poling J, Kelly L, Chan C, Fisman D, Ulanova M. Hospital admission for community-

acquired pneumonia in a First Nations population. Can J Rural Med [Internet]. 2014 Fall

[cited 2015 Apr 27];19(4):135-41. Available from: http://www.srpc.ca/14fal.html by

selecting PDF link in table of contents.

Electronic journal article, 7 or more personal authors, optional DOI information:

3. Aho M, Irshad B, Ackerman SJ, Lewis M, Leddy R, Pope T, et al. Correlation of

sonographic features of invasive ductal mammary carcinoma with age, tumor grade,

and hormone-receptor status. J Clin Ultrasound [Internet]. 2013 Jan [cited 2015 Apr

27];41(1):10-7. Available from: http://onlinelibrary.wiley.com/doi/10.1002/jcu.21990/full

DOI: 10.1002/jcu.21990

Book, personal author(s):

4. Buckingham L. Molecular diagnostics: fundamentals, methods and clinical

applications. 2nd ed. Philadelphia: F.A. Davis; c2012.

Book or pamphlet, organization as both author and publisher:

5. College of Medical Radiation Technologists of Ontario. Standards of practice.

Toronto: The College; 2011.

Book, editor(s):

6. Kumar V, Abbas AK, Aster JC, editors. Robbins basic pathology. 16th ed.

Philadelphia: Elsevier Saunders; c2013.

Book,editor(s), specific chapter with individual author(s):

7. Altobelli N. Airway management. In: Kacmarek R, Stoller JK, Heuer AJ, editors.

Egan’s fundamentals of respiratory care. 10th ed. St. Louis: Saunders Mosby; c2013. p.

732-86.

Electronic book, personal author(s), requiring password:

8. Martin A, Harbison S, Beach K, Cole P. An introduction to radiation protection

[Internet]. 6th ed. London: Hodder Arnold; 2012 [cited 2015 May 28]. Available from:

http://lrc.michener.ca:2048/login?url=http://search.ebscohost.com/login.aspx?

direct=true&db=nlebk&AN=466903&site=ehost-live&ebv=EB&ppid=pp_iii with

authorized username and password.

Electronic book, organization as author, freely available:

9. OpenStax College. Anatomy & physiology [Internet]. Version 7.28. Houston: The

College; 2013 Apr 25 [Updated 2015 May 27; cited 2015 May 28]. Available from:

http://cnx.org/content/col11496/latest/.

Dictionary entry:

10. Stedman’s medical dictionary for the health professions and nursing. 7th ed.

Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; c2012. Hematoma; p. 756.

Entry in a print reference work:

11. Canadian Pharmacists Association. CPS 2013: compendium of pharmaceuticals

and specialties. 48th ed. Ottawa: The Association; c2013. Atropine: Systemic; p. 297-9.

Entry in an online reference work:

12. Canadian Pharmacists Association. eCPS. [Internet]. Ottawa: The Association;

2015. Methimazole; [revised 2012 Mar; cited 2015 May 28]; [about 6 screens]. Available

from: http://lrc.michener.ca:2048/login/ecps with authorized username and password.

Wiki entry:

13. Wikipedia: the free encyclopedia [Internet]. St. Petersburg (FL): Wikimedia

Foundation, Inc. 2001 –   Ebola virus epidemic in West Africa; [modified 2015 May 28;

cited 2015 May 28]; [about 34 screens]. Available from:

http://en.wikipedia.org/wiki/Ebola_virus_epidemic_in_West_Africa

Newspaper article:

14. Carville O. Health ‘snooping’ cases on the rise. Toronto Star. 2015 May 27:Sect.

GT:1 (col. 3).

Electronic newspaper article:

15. Wisniewski M. Five babies at Chicago daycare diagnosed with measles. Globe and

Mail [Internet]. 2015 Feb 5 [cited 2015 Feb 6];Life:[about 2 screens]. Available from:

http://www.theglobeandmail.com/life/health-and-fitness/health/five-babies-at-chicago-

daycare-diagnosed-with-measles-report/article22805944/.

Legal material (note: this is not addressed in Vancouver Style):

16. Accessibility for Ontarians with Disabilities Act, S.O. 2005, c.11 [Internet]. 2009 Dec

15 [cited 2015 May 29]. Available from:

http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_05a11_e.htm

Report available on a web page:

17. Canadian Institute for Health Information. Depression among seniors in residential

care [Analysis in brief on the Internet]. Ottawa: The Institute; 2010 [cited 2015 May 29].

18 p. Available from:

https://secure.cihi.ca/free_products/ccrs_depression_among_seniors_e.pdf

Page on a website:

18. Alzheimer Society of Canada [Internet]. Toronto: The Society; c2015. Benefits of

staying active; 2013 Jan 28 [cited 2015 May 29];[about 1 screen]. Available from:

http://www.alzheimer.ca/en/kfla/Living-with-dementia/Day-to-day-living/Staying-active/

Benefits-of-staying-active

Streaming video:

19. Allen S, Waerlop I. The Gait Guys talk about great toe dorsiflexion [Internet]. [place

unknown]: The Gait Guys; 2014 May 11 [cited 2015 May 29]. Video: 3 min. Available

from: https://www.youtube.com/watch?v=E8O8TLtunUQ

Electronic image:

20. Bickle I. Swallowed foreign body [radiograph]. 2014 Jul 14 [cited 2015 May 29]. In:

Radiopaedia.org [Internet]. [place unknown]: Radiopaedia.org; c2005-2015. [about 1

screen]. Available from: http://radiopaedia.org/cases/swallowed-foreign-body-1

Blog post (no given name, so screen name used as author):

21. Munkee. Nuclear Munkee. [blog on the Internet]. [place unknown]:[Munkee]; [date

unknown] –   . In-111 pentetreotide imaging; 2013 Mar 19 [cited 2015 May 29]; [about 3

screens]. Available from: http://nuclearmunkee.blogspot.ca/2013/03/in-111-

pentetreotide-imaging.html

Poster presentation/session presented at a meeting or conference:

22. Chasman J, Kaplan RF. The effects of occupation on preserved cognitive

functioning in dementia. Poster session presented at: Excellence in clinical practice. 4th

Annual Conference of the American Academy of Clinical Neuropsychology; 2006 Jun

15-17; Philadelphia, PA.

Avoiding Plagiarism

From Michener’s Academic Integrity Policy and Procedure:

Plagiarism is the portrayal, claiming or use of another person’s work or ideas (sentence,

thought, paragraph, intellectual property, data, drawings or images) without specific

reference. In the academic world this is considered to be theft. It is dishonest and

irresponsible and will result in serious consequences.

As you can see from the quote above, plagiarism is taking, using, and submitting the

thoughts, writings, etc., of another person as your own. If a concept or theory is

“common knowledge” in the field, e.g., one of the symptoms of measles is a rash, you

do not need to provide a reference; if it is not common knowledge or if you are not sure,

provide a reference. Examples of concepts that require a reference include discoveries,

theories, controversies and opinions. Don’t forget to acknowledge the source of

illustrations, charts, and tables of data. For more information, consult Michener’s

Avoiding Plagiarism: Why Use References?

Writing a reference list in the Vancouver styleWhen writing a reference list in Vancouver style, you need to remember the following:

arrange your list chronologically

number all references

list the first 6 authors followed by 'et al.' if there are more than 6 authors

use official abbreviations for titles of journals (if available)

Books and anthologies

Book

Surname Initial(s). Book title. Edition - if available. Place of publication: Publisher; Year.

Dybvig DD, Dybvig M. Det tenkende mennesket. Filosofi- og vitenskapshistorie med vitenskapsteori.

2nd ed. Trondheim: Tapir akademisk forlag; 2003.

Bick J. 101 Thing You Need to Know about Internet Law [Internet]. New York: Three Rivers Press; 2000

[cited 2004 Mar 30]. Available from: http://site.ebrary.com/lib/ntnu/

Anthology (book with articles)

An anthology is a book with one editor, but where the chapters are written by several different

authors.

Surname author Initial(s). Chapter title. In: Surname editor Initial(s), editor(s). Book title. Place of

publication: Publisher; Year. page(s).

Beizer JL, Timiras ML. Pharmacology and drug management in the elderly. In: Timiras PS, editor.

Physiological basis of aging and geriatrics. 2nd ed. Boca Raton: CRC Press; 1994. p. 279-84.

Fermann G, editor. International politics of climate change: key issues and critical actors. Oslo:

Scandinavian University Press; 1997.

Journals, conferences and newspapersJournal article

Surname Initial(s). Title of article. Journal title/or title abbreviation. Year;volume(issue):page(s). DOI - if

available

Kwan I, Mapstone J. Visibility aids for pedestrians and cyclists: a systematic review of randomised

controlled trials. Accid Anal Prev. 2004;36(3):305-12. DOI: 10.1016/S0001-4575(03)00008-3

Kwan I, Mapstone J. Visibility aids for pedestrians and cyclists: a systematic review of randomised

controlled trials. Accid Anal Prev [Internet]. 2004 [cited 2004 Mar 30];36(3):305-12. Available from:

http://www.sciencedirect.com/science/journal/00014575

Conference paper

Unpublished paper:

Surname Initial(s). Paper title. Paper presented at Name of conference; Date; Place.

Published paper:

Surname author Initial(s). Paper title. In: Surname editor Initial(s), editor(s). Conference title. Place of

publication: Publisher; Year. page(s).

Nørvåg K. Space-Efficient Support for Temporal Text Indexing in a Document Archive Context. In: Koch

T, Sølvberg I, editors. Research and Advanced Technology for Digital Libraries. 7th European

Conference, ECDL; 2003 Aug 17-22; Trondheim, Norway. Berlin: Springer; 2003. p. 511-22.

Newspapers and popular magazines

Surname Initial(s). Article title. Newspaper title. Date:page.

Ringen S. La ikke Erna Solberg rasere det lokale folkestyre. Aftenposten. 2004 March 25:10.

Grosh A, Graff J. A strike at Europe’s heart. Time Magazine. 2004 March 22:22.

Dissertations, master theses and public information

Web pagesWeb page

Author. Title [Internet]. Place: Publisher; Date of publication [date updated; cited date]. Available from:

http://...

Example: reference list in the Vancouver styleReference list

1. Kwan I, Mapstone J. Visibility aids for pedestrians and cyclists: a systematic review of randomised

controlled trials. Accid Anal Prev. 2004;36(3):305-12. DOI: 10.1016/S0001-4575(03)00008-3

2. Dybvig DD, Dybvig M. Det tenkende mennesket. Filosofi- og vitenskapshistorie med vitenskapsteori.

2nd ed. Trondheim: Tapir akademisk forlag; 2003.

3. Beizer JL, Timiras ML. Pharmacology and drug management in the elderly. In: Timiras PS, editor.

Physiological basis of aging and geriatrics. 2nd ed. Boca Raton: CRC Press; 1994. p. 279-84.

4. Fermann G, editor. International politics of climate change: key issues and critical actors. Oslo:

Scandinavian University Press; 1997.

Please note that the reference list always begins on a new page.

Subject to errors.

ncouver Style: Sample Reference ListA guide to Vancouver referencing style for Murdoch University students and staff

Home Citing in the Text o Citing Personal Communications o Citing Secondary Sources

Reference List Entries o A-V Materials o Book Chapters o Books o Conference Papers o E-books o E-journals o Electronic Documents o Internet Documents o Journal Articles o Newspaper Articles o Podcasts o Readers/Study Guides o Theses

All Examples Sample Reference List Recommended URLs Abbreviations

4 Easy Steps Referencing Terms More Information ...

An Example

References

1. Hoppert M. Microscopic techniques in biotechnology. Weinheim: Wiley-VCH; 2003.

2. Drummond PD. Triggers of motion sickness in migraine sufferers. Headache. 2005;45(6):653-6.

3. Meltzer PS, Kallioniemi A, Trent JM. Chromosome alterations in human solid tumors. In: Vogelstein B, Kinzler KW, editors. The genetic basis of human cancer. New York: McGraw-Hill; 2002. p. 93-113.

4. Storey KB, editor. Functional metabolism: regulation and adaptation. Hoboken (NJ): J. Wiley & Sons; 2004.

5. Halpern SD, Ubel PA, Caplan AL. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347(7):284-7.

6. Geck MJ, Yoo S, Wang JC. Assessment of cervical ligamentous injury in trauma patients using MRI. J Spinal Disord. 2001;14(5):371-7.

7. Gillespie NC, Lewis RJ, Pearn JH, Bourke ATC, Holmes MJ, Bourke JB, et al. Ciguatera in Australia: occurrence, clinical features, pathophysiology and management. Med J Aust. 1986;145:584-90.

8. Lawhead JB, Baker MC. Introduction to veterinary science. Clifton Park (NY): Thomson Delmar Learning; 2005.

9. Ford HL, Sclafani RA, Degregori J. Cell cycle regulatory cascades. In: Stein GS, Pardee AB, editors. Cell cycle and growth control: biomolecular regulation and cancer. 2nd ed. Hoboken (NJ): Wiley-Liss; 2004. p. 42-67.

10. Gilstrap LC, Cunningham FG, Van Dorsten JP, editors. Operative obstetrics. 2nd ed. New York: McGraw-Hill; 2002.

11. The Oxford concise medical dictionary. 6th ed. Oxford: Oxford University Press; 2003. p. 26.

12. Palsson G, Hardardottir KE. For whom the cell tolls: debates about biomedicine (1). Curr Anthropol [serial online]. 2002 [cited 2005 Jun 30]; 43(2):271+[about 31 pages]. Available from: Academic OneFile. http://find.galegroup.com.

13. Murray PR, Rosenthal KS, Kobyashi GS, Pfaller MA. Medical

microbiology. 4th ed. St Louis: Mosby; 2002.

14. Barton CA, McKenzie DP, Walters EH, et al. Interactions between psychosocial problems and management of asthma: who is at risk of dying? J Asthma [serial on the Internet]. 2005 [cited 2005 Jun 30];42(4):249-56. Available from: http://www.tandf.co.uk/journals/.

15. Diabetes Prevention Program Research Group. Hypertension, insulin, and proinsulin in participants with impaired glucose tolerance. Hypertension. 2002;40(5):679-86.

16. 21st century heart solution may have a sting in the tail. BMJ. 2002;325(7537):184.

17. Dearne K. Dispensing with the chemist. The Australian [newspaper online]. Jun 14, 2005 [cited 2005 Jun 30];[about 8 screens]. Available from: Factiva. http://global.factiva.com.

18. Diseased organs may be used to deter smokers. Sydney Morning Herald [newspaper on the Internet]. Jun 29, 2005 [cited 2005 Jun 30]; para. 4-5. Available from: http://www.smh.com.au/.

19. Allen C, Crake D, Wilson H, Buchholz A. Polycystic ovary syndrome and a low glycemic index diet. Can J Diet Pract Res [serial online]. 2005 [cited 2005 Jun 30];Summer:3. Available from: ProQuest. http://il.proquest.com/.

20. Geraud G, Spierings EL, Keywood C. Tolerability and safety of frovatriptan with short- and long-term use for treatment of migraine and in comparison with sumatriptan. Headache. 2002;42 Suppl 2:S93-9.

21. Banit DM, Kaufer H, Hartford JM. Intraoperative frozen section analysis in revision total joint arthroplasty. Clin Orthop. 2002;(401):230-8.

22. O'Leary C. Vitamin C does little to prevent winter cold. The West Australian. 2005 Jun 29; 1.

23. Lee GR, Bithell TC, Foerster J, Athens JW, Lukens JN, editors. Wintrobes clinical hematology. 9th ed. Vol 2. Philadelphia: Lea & Febiger; 1993.

24. Australian Insitute of Health and Welfare. Chronic diseases and associated risk factors [document on the Internet]. Canberra: The Institute; 2004 [updated 2005 June 23; cited 2005 Jun 30]. Available from: http://www.aihw.gov.au/cdarf/index.cfm

25. Unwin E, Codde JP, Bartu A. The impact of drugs other than alchohol and tobacco on the health of Western Australians. Perth: Dept of Health; 2004. Epidemiology occasional papers series, No. 20.

26. van Belle G, Fisher LD, Heagerty PJ, Lumley TS. Biostatistics: a methodology for the health sciences [e-book]. 2nd ed.

Somerset (NJ): Wiley InterScience; 2003 [cited 2005 Jun 30]. Available from: Wiley InterScience electronic collection.

27. Christensen S, Oppacher F. An analysis of Koza's computational effort statistic for genetic programming. In: Foster JA, Lutton E, Miller J, Ryan C, Tettamanzi AG, editors. Genetic programming: EuroGP 2002: Proceedings of the 5th European Conference on Genetic Programming; 2002 Apr 3-5; Kinsdale, Ireland. Berlin: Springer; 2002. p. 182-91.

28. American Veterinary Medical Association. National Board Examination Committee. North American Veterinary Licensing Examination : bulletin of information for candidates. Bismarck (ND): The Committee; 2001.

29. Sommers-Flanagan J, Sommers-Flanagan R. Clinical interviewing [e-book]. 3rd ed. New York: John Wiley & Sons; 2003 [cited 2005 Jun 30]. Available from: NetLibrary.

30. Harnden P, Joffe JK, Jones WG, editors. Germ cell tumours V. Proceedings of the 5th Germ Cell Tumour conference; 2001 Sep 13-15; Leeds, UK. New York: Springer; 2002.

31. Australia. Commonwealth Department of Veterans' Affairs and Defence. Australian Gulf War veterans' health study 2003. Canberra: Commonwealth of Australia; 2003.

32. Australian Bureau of Statistics. Disability, ageing and carers: summary of findings. Canberra: ABS; 1999. ABS publication 4430.0.

33. Lee HC, Pagliaro EM. Serology: blood identification. In: Siegel J, Knupfer G, Saukko P, editors. Encyclopedia of forensic sciences [e-book]. San Diego: Academic Press; 2000 [cited 2005 Jun 30]:1331-8. Available from: Science Direct Reference. www.elsevier.com.

34. Lugg DJ. Physiological adaptation and health of an expedition in Antarctica: with comment on behavioural adaptation. Canberra: A.G.P.S.; 1977. Australian Government Department of Science, Antarctic Division. ANARE scientific reports. Series B(4), Medical science No. 0126.

35. Widdicombe J. Respiration. In: Blakemore C, Jennett S, editors. The Oxford companion to the body [e-book]. Oxford: Oxford University Press; 2001 [cited 2005 Jun 30]. Available from: Oxford Reference Online. http://www.oxfordreference.com.

36. Hincks CL. The detection and characterisation of novel papillomaviruses. Biomedical Science, Honours [thesis]. Murdoch (WA): Murdoch University; 2001.

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Studies of Ethical Conflicts by Nursing Practice Settings or Roles

1. Barbara K. Redman 1. University of Connecticut School of Nursing, Storrs, CT

1. Martha N. Hill 1. Center for Nursing Research and Post-Doctoral Programs, Johns Hopkins University, Baltimore, MD.

Abstract

This article summarizes the body of research about ethical conflicts described by nurses in variousfields ofpractice and recommends direction for the use and extension of this information. Twenty-three studies that fit criteria for inclusion were located. As a group, studies use inconsistent terminology, pay little attention to

measurement characteristics of the instruments used, and do not use explanatory theory about how and why ethical conflicts develop or are experienced. Several studies of nurses practicing in community and home care settings, in intensive care units, and in administrative roles show some common areas of ethical conflict. Studies of ethical conflicts can be used as a basis for improving practice.

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Ethics: Nursing Around the World: Cultural Values and Ethical Conflicts

^ m d  

http://www.nursingworld.org/MainMenuCategories/ANAMarketPlace/ANAPeriodicals/OJIN/Columns/Ethics/CulturalValuesandEthicalConflicts.aspx

Ruth Ludwick, PhD, RN, CMary Cipriano Silva, PhD, RN, FAAN

Citatation: Ludwick, R., Silva, M.C., (August 14, 2000) "Ethics: Nursing Around the World: Cultural Values and Ethical Conflicts" Online Journal of Issues in Nursing Vol. 5 No. 3 Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/Ethics/CulturalValuesandEthicalConflicts.aspx

Keywords: culture, cultural values, ethical conflicts

Related Issue: "Nursing Around the World"

In a recent article, Heller, Oros, and Durney-Crowley (2000) note 10 trends to watch regarding the future of nursing education. The first trend listed relates to diversity and its impact on disease and illness and the subsequent challenge to change education and practice to be congruent and respectful of differing values and beliefs. In a like manner other authors (e.g., Bellack& O’Neil, 2000;  Gibson, 2000   ; Hegyvary, 2000; Outlaw, 1997) have called attention to the need for closer scrutiny of our values and beliefs about diversity. Outlaw, for example, expressively requests "a call for scholarly inquiry on human diversity" (p. 69). 

Implicit or explicit in the works of these authors are the notions of culture and of values. Both words have many interpretations but each word has a primary association with a discipline. Culture’s primary homebase is anthropology. Value’s primary homebase is philosophy, especially as it relates to ethics. One can identify subsets of words associated with each. For culture, terms that immediately come to mind are ethnocentrism, cultural imposition, cultural importation, and cultural exportation. (Seedefinitions and assumptions) For values, terms that immediately come to mind are belief systems and norms. The rubber meets the road when the two terms are joined: cultural values. Therefore, our purpose in writing this article is threefold: a) to clarify the relationships among cultural values, ethics, and ethical conflicts; b) to demonstrate with examples from the culture predominant in the United States how cultural attitudes and values in nursing may lead to conflict as a result of increasing globalization, and c) to formulate nursing strategies to decrease ethical conflicts related to cultural values.

Cultural Values, Ethics, and Ethical Conflicts

Cultural values refer to enduring ideals or belief systems to which a person or a society is committed. The values of nursing in the States are, for example, embedded in the values of the U.S. American culture with its emphasis on self-reliance and individualism (Davis, 1999). Basic to the value placed on individualism are the beliefs that "individuals have the ability to pull themselves up by their bootstraps" and that an individual’s rights are more important than a society’s. 

However, many cultures do not share the primacy of the value of individualism. Consider the factual data presented by Davis that about 70% of all cultures are collectivistic (i.e., loyalties of a person to a group exceed the rights of the individual) rather than individualistic (i.e., the rights of the individual supercede those of the group). "With individualism, importance is placed on individual inputs, rights and rewards" (Andrews, 1999, p. 476). In many cultures, health decisions are not made by an individual but by a group: family, community and/or society. Socialized medicine or government sponsored health care for all residents is reflective of the value placed on collectivism.

Therefore, reflecting on the values that predominate in the culture you practice, attain an education, visit, or read about is a requirement for ethical thoughtfulness. Ethics has many definitions but, typically, ethics is viewed as a systematic way of examining the moral life to discern right and wrong; it also requires a decision or action based on moral reasoning. Ethical conflicts occur when a person, group or society is uncertain about what to do when faced with competing moral choices (Silva, 1990). Ethical conflicts and issues occur within or among cultures and are usually precipitated by cultural/subcultural values in opposition. 

Conflict and Globalization

Certainly members of any culture may hold varying degrees of commitment to the predominant values of the culture, but being in opposition to those values sets the stage for conflict. Even countries where people were once relatively isolated from other cultures or were homogenous (e.g., Asian cultures) are also becoming more culturally diverse. Why? Through increased communication, travel, and trade, differing perspectives have been imposed upon the cultural beliefs and ethical values of people because they are believed to be right or better (ethnocentrism at work). For example, North Americans and others with Western ethical perspectives who live in their own homelands may, unwittingly, export products abroad like textbooks, curriculums, and used equipment. These products, even though well intentioned, may present a cultural imposition. In addition, the altered attitudes of international students who return to their homeland after a westernized education in a capitalistic culture are a source of inculcating new but perhaps unsettling ethical perspectives on a country or profession. Globalization, with its outcome of increased cultural diversity, has not only given nurses pause for thought but also has contributed to ethical conflicts. 

Davis (1999) recognizes how ethical conflicts and issues can arise, especially when nurses acknowledge the profound influence that the values of nurses in the United States have had on other countries worldwide. The value on individualism, for U.S. nurses, for example, can be examined in relation to the ethical principles of autonomy and justice. The ethical principle of autonomy is related to self- determination, that is, the individual’s right to make decisions for him or herself. Consistent with this principle is respect for the autonomy of others. Therefore, the lack of respect for the decision-making of culturally diverse people in nursing practice is unethical.

The other principle, justice, which deals with what is due or owed to an individual, group, or society, has numerous definitions. For this discussion, we focus on two conflicting material principles of justice that cause ethical conflict: 1) "to each person according to what can be obtained in a free market, " 2) "to each person based on need." 

The first material principle of justice has autonomy as its underpinning. It is in keeping with a supply and demand situation where some persons will possess or benefit more than other persons. A problem with this principle is that it can lead to inequalities in society’s burdens and benefits.

The second material principle of justice has fairness as its underpinning. It is sensitive to individual differences and to factors over which the person has no control. A problem with this principle is how to honor it when resources are finite or scarce.

While we have only examined ethical conflicts that evolve from the U. S. cultural emphasis on individualism and the related ethical principles of autonomy and justice, there are many other examples of conflicts that can be and should be examined, but go beyond the scope and purpose of this column. However, we leave the reader with two questions to consider that are particularly cogent to a discussion on ethical conflicts: "…is it justified to strive for uniformity of nursing practice on the basis of ethics across all cultures?" and "…are there ethical notions of caring, ethical principles and virtues, that could be endorsed as true for all nurses everywhere?" (Davis, 1999, p. 123). 

Nursing Strategies to Decrease Ethical Conflicts Related to Cultural Values and Diversity

Of the many nursing theories used in the United States today, the one most associated with culture and cultural values is Leininger’s (1991) Culture Care Diversity and Universality: A Theory of Nursing. In the mid-1950s she first observed that nursing practice lacked attention to cultural and humanistic factors. It was from these observations and from further writing and research on the topic that the preceding book was written (Leininger, 1996). Implicit to her theory is the importance of communication between patient/client and the provider(s) of care. As Donnelly (2000) succinctly states, "...ethical issues become more prominent when a lack of communication occurs" (p. 124). Lack of communication is more likely to occur when nurses care for international and culturally diverse persons. The resultant misunderstandings can lead to lack of respect for persons whose cultural values are different from one’s own and to potential and real harm to those persons, whether culturally, psychologically, physically, or spiritually.

How can the situation be improved? Here are some suggestions to improve communication and nursing care and, thus, decrease ethical conflicts:

1. Recognize that values and beliefs vary not only among different cultures but also within cultures. 2. View values and beliefs from different cultures within historical, health care, cultural, spiritual, and

religious contexts. 3. Learn as much as you can about the language, customs, beliefs and values of cultural groups,

especially those which you have the most contact. Related Links from Transcultural Nursing: Basic Concepts and Case StudiesAvailable: www.culturediversity.org/links.htm. 

4. Be aware of your own cultural values and biases, a major step to decreasing ethnocentrism and cultural imposition. (A questionnaire that can help you with this goal can be found in Andrews and Herberg, 1999). 

5. Be alert to and try to understand the nonverbal communications of your own and various cultures such as personal space preferences, body language, and style of hair and clothing. 

6. Be aware of biocultural differences manifested in the physical exam, in types of illness, in response to drugs, and in health care practices.

Terms & Definitions

Ethnocentrism - A person’s belief in the inherent superiority of one’s own culture over that of other cultures.

Cultural Imposition - A situation where one culture forces their values and beliefs onto another culture or subculture.

Cultural Importation - A situation where one culture buys or brings in products and goods from foreign countries (cultures) to be used or sold in the importing culture.

Cultural Exportation - A situation where one culture sends products or goods to foreign countries (cultures) to be used or sold in the exporting culture.

Belief Systems - A totality of enduring facts, principles and values that a person or a  culture deems to be true or to be trusted.

Norms - Standards that are accepted, often implicitly, by a culture.

Assumptions

1. Goods or products imported/exported intact to another culture may not meet the needs of that culture or therefore, may need modification. 

2. Both ethnocentrism and cultural imposition show insensitivity to the culture(s) who receive them. 3. Both belief systems and norms are needed for a stable culture.

Authors

Ruth Ludwick, PhD, RN, CMary Cipriano Silva, PhD, RN, FAAN

References

Andrews, M. M. (1999). Cultural diversity in the health care workforce. In M. A. Andrews & J. S. Boyle, Transcultural concepts in nursing care (3rd ed., pp 471-506). Philadelphia: Lippincott.

Andrews, M. M., & Herberg, P. (1999). Transcultural nursing care. In M. A. Andrews & J. S. Boyle, Transcultural concepts in nursing care (3rd ed., pp 25-27). Philadelphia: Lippincott.

Bellack, J. P., & O’Neil, E. H. (2000). Recreating nursing practice for a new century: Recommendations and implications of the PEW health professions commission’s final report. Nursing and Health Care Perspectives, 21(1), 14-21.

Davis, A. J. (1999). Global influence of American nursing: Some ethical issues. Nursing Ethics: An International Journal for Health Care Professionals, 6(2), 118-125.

Donnelly, P. L. (2000). Ethics and cross-cultural nursing. Journal of Transcultural Nursing, 11(2), 119-126.

Gibson, D. M. (2000). The internationalization of higher education. In M. L. Kelley & V. M. Fitzsimons (Eds.), Understanding cultural diversity: Culture, curriculum, and community in nursing. Boston: Jones and Bartlett.

Hegyvary, S. T. (2000). Scholarship for a new era. Journal of Nursing Scholarship, 32, 4-5.

Heller, B. R. , Oros, M. T., & Durney-Crowley, J. (2000). The future of nursing education: 10 trends to watch. Nursing and Health Care Perspectives, 21(1), 9-13.

Leininger, M. (1991). Culture care diversity and universality: A theory of nursing. New York: National League for Nursing Press.

Leininger, M. (1996). Culture care theory, research, and practice. Nursing Science Quarterly, 9 (2), 71-78.

Outlaw, F. (1997). A call for scholarly inquiry on human diversity. In V. D. Ferguson (Ed.), Educating the 21st century nurse: Challenges and opportunities (pp. 69-90). New York: National League for Nursing Press.

Silva, M. C. (1990). Ethical decision making in nursing administration (pp. 40-80). Norwalk, CT: Appleton & Lange.

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Journal of advanced nursing

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.1995.tb02651.x/abstract

Nursing and nurse education have been influenced by a shift towards a broadly humanistic philosophy as a basis for

practice At the same time, in attempts to develop a knowledge base and credibility as a profession, the vital

importance of research has been acknowledged Both these aspects of nursing are increasingly forming the basis for

all nursing courses However, in this paper, it is argued that the implicit adoption of notions of science based in a

positivistic paradigm gives rise to conflicts with a humanistic philosophy It is contended that nursing has inherited a

‘legacy of positivism’, which promotes objectivity and reductionism and which excludes subjective meaning and the

personal from the research process In part this has been due to the powerful influence of medical hegemony, which

has defined the nature of legitimate knowledge and controlled nursing research through the gatekeeping function of

doctors If nursing is to make progress in the development of a knowledge base, the contradictions between

humanism and positivism must be acknowledged as a barrier to an integration of the art and science of nursing This

paper suggests that what is required is a paradigm shift, a redefinition of nursing science, which not only

rehumanizes the nature of research, but also refutes and challenges the notion of objectivity and the objective

attitude

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http://onlinelibrary.wiley.com/doi/10.1002/j.2048-7940.1995.tb01628.x/abstracturses' Perceptions of Their Role and Role Conflicts

1. Linda Benson PhD RN†,* and

2. Alex Ducanis PhD†

Article first published online: 3 SEP 2012

DOI: 10.1002/j.2048-7940.1995.tb01628.x

1995 Association of Rehabilitation Nurses

Issue

Rehabilitation Nursing

Volume 20, Issue 4, pages 204–211, July-August 1995

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Nurses' perceptions of their professional role and their experience of role conflict were explored in a sample of

certified general rehabilitation nurses. Nonnurse healthcare professionals who are on the same teams as the

participating nurses also were assessed for their expectations of the nurse's role. The level of locus of control was

identified among the various professions. The major finding of the study was that the rehabilitation nurses shared a

consistent view of their professional role and of how they believed other professionals saw this role. The results

showed that the nonnurse professionals were to some extent unaware of the expectations that the nurses held for the

nursing role. There was no appreciable difference in the level of locus of control among team members, a situation

In this issue

which may have a leveling effect on the team dynamics. These findings have implications for professional role clarity,

the promotion of locus of control, and interdisciplinary team dynamics.

Medical TherapyNeonatal care

When a neonate with a cleft is born, a pediatrician has 3 major concerns:

Risk of aspiration because of communication between oral and nasal cavities Airway obstruction (in addition to sequelae of aspiration, especially in Robin sequence in which the cleft

palate [CP] is combined with micrognathia and the tongue has a normal size) Difficulties with feeding of a child with a cleft and nasal regurgitation

These 3 factors are influenced by the presence of other major or minor anomalies that may, in association with a cleft, represent 1 of 300 known cleft syndromes.[11]Therefore, a neonate with an orofacial cleft should be seen by a medical geneticist as soon as possible.

As with any other medical condition, each case is different. A child with a severe cleft may do very well, whereas a child with a much less severe condition may experience many problems. An individual approach is necessary; however, several major rules apply to every neonate born with a cleft.

A pediatrician/neonatologist is usually the first person to take care of a neonate born with a cleft and the first to talk to the parents. As soon as possible, refer each baby born with orofacial cleft to the cleft palate or craniofacial center, where each specialist evaluates the baby, delineates the best management options and treatment plan, and continuously revises individual procedures and treatment during follow-up visits.

Feeding an infant with a cleft

The vast majority of children with cleft lip and palate (CLP) anomalies are born with a normal birth weight. However, because of feeding and other difficulties mentioned above, the most common problem the pediatrician has to deal with is insufficient weight gain. One of the pediatrician's main responsibilities is to closely monitor the infant's weight. Pediatricians may supervise mothers themselves or may refer them to a nutritionist, feeding specialist, experienced nurse practitioner, or other specialist.

Most children born with cleft lip and palate are unable to be breastfed. Those with cleft palate cannot produce the negative pressure necessary for suction. Mothers of children with a unilateral cleft lip may succeed with breastfeeding when the child is positioned so that the cleft in the lip is obstructed by the mother's breast.

No single right or correct method of feeding has been identified. Parents working together with the health care provider should choose the method that is best for their infant. Most infants can complete a feeding in 18-30 minutes. If more than 45 minutes is required, the infant may be working too hard and may be burning calories that should be used for weight gain. An infant who nurses or bottle feeds every 3-4 hours tends to gain weight better than an infant who feeds frequently (< 2 h apart) for short periods.

Helpful hints for a parent are as follows:

Breastfeeding an infant with a clefto In a case of an isolated cleft lip, the infant typically does not experience feeding problems beyond learning

how to "latch on" to the nipple at the beginning of the feeding. Infants with cleft palate must squeeze the milk out of the nipple by compressing the nipple between the tongue and whatever portion of the palate that remains.

o Massaging the breast and applying hot packs on the breast 20 minutes before nursing usually helps.o The mother should apply pressure to the areola with her fingers to help the engorged nipple protrude. She

should hold the infant in a semi-upright, straddle, or football position. She should support the breast by

holding it between her thumb and middle finger, making sure that the infant's lower lip is turned out and the tongue is under the nipple.

o If the infant cannot hold onto the nipple any more, the mother can collect the remaining milk using an electrical or manual breast pump or by squeezing the breast with both hands and can finish the feeding with collected milk in a bottle.

o The mother should increase her fluid intake (drink lots of water). Feeding breast milk with a bottleo Particularly for infants with bilateral cleft lip and palate, breastfeeding is not possible.o The mother can use a breast pump (an electric pump ensures the highest level of success). Then, she can

feed the baby with a bottle (see below). Feeding milk formula with a bottleo The most appropriate milk formula should be selected by a pediatrician or feeding specialist.o Various nipples and bottles are made specifically for infants with clefts. The goal is to find a nipple and

bottle that make feeding easy for the infant and still allow ample opportunity to suck.o A soft nipple is generally better than a hard nipple (some can be softened by boiling).o Use a crosscut nipple to prevent choking. Any nipple can be crosscut manually using a single-edged razor

blade. The crosscut is on the tongue side.o The bottle should be squeezed and released, not continually squeezed.o The nipple is angled to a side of the mouth, away from the cleft.

Other recommendationso More upright or seated positions prevent the milk from leaking to the nose and causing the infant to choke.o Advise the mother to stop feeding and allow the infant to cough or sneeze for a few seconds when nasal

regurgitation occurs. A palatal obturator may be used.Gaining weight and preventing aspiration and ear infections are the most important parts of caring for neonates with a cleft during their first days and weeks of life.

Multidisciplinary team

Most individuals with cleft lip, cleft palate, or both (and many individuals with other craniofacial anomalies) require the coordinated care of providers in many fields of medicine and dentistry, as well as those in speech pathology, otolaryngology, audiology, genetics, nursing, mental health, and social medicine.

Treatment of cleft lip and palate anomalies requires years of specialized care and is costly. The average lifetime medical cost for treatment of one individual affected with a cleft lip and palate is $100,000. [1] Although successful treatment of the cosmetic and functional aspects of orofacial cleft anomalies is now possible, it is still challenging, lengthy, costly, and dependent on the skills and experience of a medical team. This especially applies to surgical, dental, and speech therapies.

Because otitis media with effusion is very common among children with cleft palates, involvement of an otolaryngologist in the multidisciplinary treatment plan is very important. The otolaryngologist performs placement of ventilation tubes in conjunction with the cleft palate repair.[39] If a concurrent cleft lip is present, the ventilation tubes are placed during that repair. Many of these children see otolaryngologists well beyond the time they see many of the other specialists because some children continue to have eustachian tube dysfunction after their palates are closed.

A team for the multidisciplinary treatment of a child with an orofacial cleft includes the following specialists:

Pediatrician Nurse practitioner Plastic surgeon Pediatric dentist Otolaryngologist Geneticist Genetic counselor Speech pathologist Orthodontist Maxillofacial surgeon Social worker Psychologist

No single treatment concept has been identified, especially for a cleft lip and palate. The timing of the individual procedures varies in different centers and with different specialists.

Below is the most common treatment protocol presently used in most cleft treatment centers:

Newborn - Diagnostic examination, general counseling of parents, feeding instructions, palatal obturator (if necessary); genetic evaluation and specification of diagnosis; empiric risk of recurrence of cleft calculated; recommendation of a protocol for the prevention of a cleft recurrence in the family

Age 3 months - Repair of cleft lip (and placement of ventilation tubes) Age 6 months - Presurgical orthodontics, if necessary; first speech evaluation Age 9 months - Speech therapy begins Age 9-12 months - Repair of cleft palate (placement of ventilation tubes if not done at the time of cleft lip

repair) Age 1-7 years - Orthodontic treatment Age 7-8 years - Alveolar bone graft Older than 8 years - Orthodontic treatment continues

Other surgical procedures can be performed in patients with severe clefts as necessary (see Surgical Therapy).

Next Section: Surgical Therapy  

READ MORE ABOUT PEDIATRIC CLEFT LIP AND PALATE ON MEDSCAPE

RELATED REFERENCE TOPICS

Pediatric Congenital Diaphragmatic HerniaPediatric Hypernatremia

RELATED NEWS AND ARTICLES

Comparing Caries Risk Profiles Between 5- and 10- Year-Old Children With Cleft Lip and/or Palate and Non-cleft ControlsManaging the Difficult Airway in the Syndromic ChildAssociation of Breastfeeding and Three-dimensional Dental Arch Relationships in Primary Dentition

Surgical TherapyUndoubtedly, closure of the cleft lip is the first major procedure that tremendously changes children's future development and ability to thrive. Variations occur in timing of the first lip surgery; however, the most usual time occurs at approximately age 3 months. Pediatricians used to strictly follow a rule of "three 10s" as a necessary requirement for identifying the child's status as suitable for surgery (ie, 10 lb, 10 mg/L of hemoglobin, and age 10 wk). Although pediatricians are presently much more flexible, and some surgeons may well justify a neonatal lip closure, considering the rule of three 10s is still very useful.

Anatomical differences predispose children with cleft lip and palate and with isolated cleft palate to ear infections. Therefore, ventilation tubes are placed to ventilate the middle ear and prevent hearing loss secondary to otitis media with effusion. In multidisciplinary teams with significant participation of an otolaryngologist, the tubes are placed at the initial surgery and at the second surgery routinely. The hearing is tested after the first placement when ears are clear with tubes. If no cleft surgery is planned early, placing the tubes by age 6 months and monitoring hearing with repeated testing is recommended. Complications include eardrum perforation and otorrhea, particularly in patients with open secondary palates in which closure is planned for later.

For preventive reasons, ear tubes are usually placed when the child is still undergeneral anesthesia for cleft repair.

Detailed surgical treatment is described elsewhere (see surgical articlesCraniofacial, Bilateral Cleft Lip Repair, Craniofacial, Bilateral Cleft Nasal Repair,Craniofacial, Unilateral Cleft Nasal Repair, Craniofacial,

Unilateral Cleft Lip Repair). Pediatricians may find it useful to inform parents of the kinds of procedures with a child with cleft may undergo.

The most common surgical procedures for a child with a cleft lip and palate anomaly are as follows:

Repair of the cleft lip Repair of the cleft palate Revision of the cleft lip Closure and bone grafting of the alveolar cleft Closure of palatal fistulae Palatal lengthening Pharyngeal flap Pharyngoplasty Columellar lengthening Cleft lip rhinoplasty and septoplasty Lip scar revision LeFort I maxillary osteotomy

In addition, orthodontic treatment is very specialized and varies case by case. The 2 stages of orthodontic treatment of a child with cleft lip and palate are as follows:

Surgery-related orthodonticso Early management (since birth until the time of surgical closure of the palate)o Orthodontics related to alveolar bone grafto Permanent dentition management

Cleft-related orthodontics (not related to surgical treatments)Patient Education

For excellent patient education resources, visit eMedicineHealth's Children's Health Center.

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Future and ControversiesAvailable research on the association between orofacial clefts and folic acid consumption highly suggests that a certain proportion of these serious anomalies can be prevented by periconceptional supplementation of folic acid and multivitamins. The preventive approach is assumed to be especially successful in those situations in which environmental factors represent a substantial part of the etiological background.

Primary prevention (ie, prevention of a birth defect before it develops in the embryo or fetus) is attempted for prevention of recurrences in at-risk families in which a previous baby with the anomaly has been born; it is also applicable in the general population for prevention of occurrences.

More than 20 years after the first studies in experimental animals indicated that vitamin deficiency in a mother could cause congenital malformations in the offspring,[40, 41, 42] formiminoglutamic acid excretion testing for

defective folate metabolism was found to be positive more often in women pregnant with a child with a neural tube defect (NTD) or other congenital abnormality than in control subjects.[43] Furthermore, periconceptional supplementation with multivitamins[44]or folic acid (Laurence, 1981)[45] was found to have a role in the prevention of NTDs.

Nonetheless, prevention of congenital anomalies seemed impossible to realize as the ultimate goal of teratology,[46] until a randomized, controlled, double-blind, multicenter trial sponsored by the British Medical Research Council (MRC) showed a 72% decrease in the recurrence of NTDs when women ingested 4 mg/d of folic acid from the day of randomization before conception and during 12 weeks thereafter.[47, 48]

However, prophylactic multivitamin therapy, including folic acid, was first used to prevent cleft lip (CL) and palate (CLP) anomaly in future offspring of women whose first child had cleft lip with or without cleft palate (CL/P).[49, 50, 51]

Based on the results of those studies, Burian (of the Czechoslovak Academy of Sciences in Prague) initiated a study in which women who had given birth to a child with an orofacial cleft began taking the multivitamin supplement preparation Spofavit (vitamins A, B-1, B-2, B-6, C, D-3, and E; nicotinamide; and calcium pathothenicum) either immediately after a subsequent pregnancy was confirmed or periconceptionally when pregnancy had been planned.[52] Although Burian's observations were mainly empirical, a prospective trial of periconceptional multivitamin and high folic acid supplementation was conducted in women at risk of giving birth to a child with a cleft lip with or without cleft palate.

In a nonrandomized interventional study completed in the Czech Republic, a dramatic reduction of cleft recurrences was found after periconceptional supplementation with multivitamins and a high dose of folic acid.[53, 26] In this study, 221 pregnancies in women at risk for a child with a cleft lip and palate were prospectively evaluated. The 10-step protocol included multivitamin supplementation with Spofavit and folic acid (10 mg/d), beginning at least 2 months before planned conception and continuing for at least 3 months thereafter. A comparison group comprised 1901 women at risk of giving birth to a child with a cleft lip with or without cleft palate; this group received no supplementation and gave birth within the same period as the study group.

In the supplemented group, 3 of 214 informative pregnancies resulted in neonates with cleft lip with or without cleft palate, a 65.4% decrease from the expected value (see the image below).

Subset analysis by proband sex, severity of cleft lip with or without cleft palate, and both variables showed the highest supplementation efficacy in probands with unilateral cleft (82.6% decrease from the expected value).

Recurrence of clefts in supplemented and nonsupplemented groups.No efficacy was observed for female probands with bilateral cleft lip with or without cleft palate. Generally, the efficacy was higher for subgroups with unilateral clefts than for those with bilateral clefts and for male than for female probands (see the image below).

Prevention of cleft lip and palate by periconceptional vitamin (with particularly high folic acid) supplementation.Similarly, a large population-based case control study of fetuses and live-born infants in the 1987-1989 cohort of births in California reported that periconceptional use of multivitamins, which usually contain 0.4 mg or more of folic acid, reduced the occurrence of cleft lip with or without cleft palate by approximately 27-50% (see the image below).[54] In this study, 734 mothers with an infant with an orofacial cleft and 734 control mothers with an infant without a birth defect were evaluated.

Recurrence of clefts in supplemented and nonsupplemented groups, severity of cleft.In contrast, the study completed by Hayes did not support a protective association between the periconceptional folic acid supplementation and the risk of oral cleft.[55]

However, the most interesting results that strongly support using a high dose of folic acid in the prevention of nonsyndromic clefts are those of Czeizel and his colleagues in the Hungarian Case-Control Surveillance of Congenital Anomalies.[56, 57] The Hungarian randomized double-blind, controlled trial of periconceptional supplementation with a multivitamin including a low "physiologic" (as the authors call it) dose of folic acid (0.8 mg/d) did not show any preventive effect on the first occurrence of isolated cleft lip with or without cleft palate and cleft palate alone.[56, 57] However, the general evaluation of congenital anomalies in this study indicated a reduction of nonsyndromic clefts after the use of high doses of folic acid (3-9 mg/d) in the early postconception period.[57]

Czeizel's latest article discusses these 2 controversial findings and suggests a "dose-dependent effect" of folic acid in the prevention of orofacial clefts.[56]

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READ MORE ABOUT PEDIATRIC CLEFT LIP AND PALATE ON MEDSCAPE

RELATED REFERENCE TOPICS

Pediatric Congenital Diaphragmatic HerniaPediatric Hypernatremia

RELATED NEWS AND ARTICLES

Comparing Caries Risk Profiles Between 5- and 10- Year-Old Children With Cleft Lip and/or Palate and Non-cleft ControlsManaging the Difficult Airway in the Syndromic ChildAssociation of Breastfeeding and Three-dimensional Dental Arch Relationships in Primary Dentition

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