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Writing a Bibliography: APA Format

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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 monthday-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 wellbeing. 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 wellbeing. 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.

(Mnnich & 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:10.1037/0003066X.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 macroeconomics (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
fromhttp://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/CA25
68710006989...$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 Encyclopdia 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. 345349). 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-0505-00240.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/doc8893/0114-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_unde
r_strain/

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

APA

Book with one author

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.

^ top

Book with an editor

APA

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.

^ top

Journal article - one author

APA

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.

^ top

Journal article - 3 authors

APA

Author's last name, First and Second Initial., Authors last name, First and
Second Initial., & Authors 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.

^ top

Newspaper article

APA

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 computercaused injuries. Globe and Mail, pp. A1, A4.

^ top

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
DOI
examples:
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.2006.03.002
Clausen, J. A. (1967). The organism and socialization. Journal of Health
and Social Behavior, 8, 243-252. Retrieved from JSTOR.

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Lecture

APA

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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Interview

APA

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 page

APA

Authors 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=210131390
Call of Duty zombies. (n.d.). Retrieved
from http://www.callofdutyzombies.com/

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Email

APA

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 citations

APA

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 Michener
The 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 authors 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 lowercase, 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 Medlines 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).

Indicate date of retrieval, preceded by the word cited, in square brackets after
the date of publication (see example 2).

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).

If a DOI exists, it is optional to add it after the retrieval information (see example
3).

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, 2nd 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 communityacquired 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.
Egans 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. Stedmans 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-chicagodaycare-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.elaws.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/Stayingactive/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-111pentetreotide-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 Micheners Academic Integrity Policy and Procedure:
Plagiarism is the portrayal, claiming or use of another persons 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. Dont forget to acknowledge the source of
illustrations, charts, and tables of data. For more information, consult Micheners
Avoiding Plagiarism: Why Use References?

Writing a reference list in the Vancouver style

When 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 newspapers

Journal 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).

Nrvg K. Space-Efficient Support for Temporal Text Indexing in a Document Archive Context. In: Koch
T, Slvberg 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 Europes heart. Time Magazine. 2004 March 22:22.

Dissertations, master theses and public information

Web pages
Web page
Author. Title [Internet]. Place: Publisher; Date of publication [date updated; cited date]. Available from:
http://...

Example: reference list in the Vancouver style

Reference 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 List

A guide to Vancouver referencing style for Murdoch University students and staff

Home

Citing in the Text

Citing Personal Communications

Citing Secondary Sources

Reference List Entries

A-V Materials

Book Chapters

Books

Conference Papers

E-books

E-journals

Electronic Documents

Internet Documents

Journal Articles

Newspaper Articles

Podcasts

Readers/Study Guides

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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first). Vol.(if a multivolume work). Place of
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1. Hoppert M. Microscopic techniques in biotechnology. Weinheim: Wiley-VCH; 2003.
2. Storey KB, editor. Functional metabolism: regulation and adaptation. Hoboken (NJ): J. Wiley & Sons; 2004.
Two or more authors or editors
3. Lawhead JB, Baker MC. Introduction to veterinary science. Clifton Park (NY): Thomson Delmar Learning; 2005.
4. Gilstrap LC, Cunningham FG, Van Dorsten JP, editors. Operative obstetrics. 2nd ed. New York: McGraw-Hill;
2002.
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5. Murray PR, Rosenthal KS, Kobyashi GS, Pfaller MA. Medical microbiology. 4th ed. St Louis: Mosby; 2002.
No author
6. The Oxford concise medical dictionary. 6th ed. Oxford: Oxford University Press; 2003. p. 26.
Multivolume work
7. Lee GR, Bithell TC, Foerster J, Athens JW, Lukens JN, editors. Wintrobes clinical hematology. 9th ed. Vol 2.
Philadelphia: Lea & Febiger; 1993.
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8. 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
Organisation
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Licensing Examination: bulletin of information for candidates. Bismarck (ND): The Committee; 2001.
Government publications
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study 2003. Canberra: Commonwealth of Australia; 2003.
11. Australian Bureau of Statistics. Disability, ageing and carers: summary of findings. Canberra: ABS; 1999. ABS
publication 4430.0.
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12. 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.
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13. Pagedas AC, inventor; Ancel Surgical R&D Inc., assignee. Flexible endoscopic grasping and cutting device and
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Studies of Ethical Conflicts by Nursing Practice Settings

or Roles
1.
1.
1.
1.

Barbara K. Redman
University of Connecticut School of Nursing, Storrs, CT
Martha N. Hill
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

^md

http://www.nursingworld.org/MainMenuCategories/ANAMarketPlace/ANAPeriodicals/OJIN/Columns/Ethics/Cu
lturalValuesandEthicalConflicts.aspx
Ruth Ludwick, PhD, RN, C
Mary 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/CulturalV
aluesandEthicalConflicts.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& ONeil, 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. Cultures primary homebase
is anthropology. Values 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
individuals rights are more important than a societys.
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 individuals 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 societys 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 Leiningers (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 ones 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 persons belief in the inherent superiority of ones 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, C
Mary 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., & ONeil, E. H. (2000). Recreating nursing practice for a new century: Recommendations and
implications of the PEW health professions commissions 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
Get PDF (545K)

http://onlinelibrary.wiley.com/doi/10.1002/j.2048-7940.1995.tb01628.x/abstract
urses' 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 204211, July-August 1995

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Abstract
References
Cited By

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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
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 Therapy
Neonatal 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:

o
o

o
o

o
o

o
o
o
o
o
o

Breastfeeding an infant with a cleft

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.
Massaging the breast and applying hot packs on the breast 20 minutes before nursing usually
helps.
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.
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.
The mother should increase her fluid intake (drink lots of water).
Feeding breast milk with a bottle
Particularly for infants with bilateral cleft lip and palate, breastfeeding is not possible.
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 bottle
The most appropriate milk formula should be selected by a pediatrician or feeding specialist.
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.
A soft nipple is generally better than a hard nipple (some can be softened by boiling).
Use a crosscut nipple to prevent choking. Any nipple can be crosscut manually using a singleedged razor blade. The crosscut is on the tongue side.
The bottle should be squeezed and released, not continually squeezed.
The nipple is angled to a side of the mouth, away from the cleft.
Other recommendations

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.
o

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

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Surgical Therapy
Undoubtedly, 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:

o
o
o

Surgery-related orthodontics
Early management (since birth until the time of surgical closure of the palate)
Orthodontics related to alveolar bone graft
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 Controversies
Available 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

RELATED NEWS AND ARTICLES

Pediatric Congenital Diaphragmatic

Comparing Caries Risk Profiles

Hernia
Between 5- and 10- Year-Old Children
With Cleft Lip and/or Palate and Non
Pediatric Hypernatremia
cleft Controls

Managing the Difficult Airway in the

Syndromic Child

Association of Breastfeeding and

Three-dimensional Dental Arch
Relationships in Primary Dentition
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