School Attendance Among Pediatric Oncology Patients During the COVID-19 Pandemic in Ontario, Canada.

Supporting schooling for current and past pediatric oncology patients is vital to their quality of life and psychosocial recovery. However, no study has examined the perspectives toward in-person schooling among pediatric oncology families during the COVID-19 pandemic. In this online survey study, we determined the rate of and attitudes toward in-person school attendance among current and past pediatric oncology patients living in Ontario, Canada during the 2020-2021 school year. Of our 31-family cohort, 23 children (74%) did attend and 8 (26%) did not attend any in-person school during this time. Fewer children within 2 years of treatment completion attended in-person school (5/8; 62%) than those more than 2 years from treatment completion (13/15; 87%). Notably, 22 of 29 parents (76%) felt that speaking to their care team had the greatest impact compared to other potential information sources when deciding about school participation, yet 13 (45%) were unaware of their physician's specific recommendation regarding whether their child should attend. This study highlights the range in parental comfort regarding permitting in-person schooling during the COVID-19 pandemic. Pediatric oncologists should continue to address parental concerns around in-person school during times of high transmission of COVID-19 and potentially other communicable diseases in the future.

Validation of published rebound hyperbilirubinemia risk prediction scores during birth hospitalization after initial phototherapy: a retrospective chart review.

BACKGROUND: Hyperbilirubinemia commonly affects newborns and may lead to neurotoxicity if untreated. Neonates can experience rebound hyperbilirubinemia (RHB), defined as elevated bilirubin levels requiring re-initiation of treatment. Although studies have formulated risk prediction scores, they lack external validation. In this study, we examine the discrimination and calibration performance of risk prediction scores for RHB, to provide external validation. METHODS: We reviewed charts of neonates born ≥35 weeks of gestation between January 2015 and December 2019 receiving phototherapy at birth hospitalization. We plotted predicted probabilities against observed outcome proportions to assess model calibration and evaluated discrimination using area under the receiver operating characteristic (AUROC) curves. Odds ratios (ORs) were estimated to evaluate variables associated with RHB. RESULTS: Of the 271 infants identified, 24% developed RHB. Two- and three-variable prediction scores had lower discrimination in our cohort with AUROC of 0.662 (95% CI 0.590-0.735) and 0.691 (95% CI, 0.619-0.763) compared to 0.876 (95% CI 0.854-0.899) and 0.881 (95% CI 0.859-0.903), respectively, in the published studies. Estimated ORs confirm associations between RHB and variables included in prediction scores. CONCLUSIONS: Current prediction models for RHB have unclear clinical utility in our patient population. Additional studies are required to further validate these scores. IMPACT: Describes performance characteristics of two- and three-variable risk prediction scores that lack external validation beyond the initial study cohort. Our findings suggest unclear clinical utility in our clinical population of neonates during birth hospitalization, with lower performance of these prediction scores than observed in the derivation cohort. Odds ratios estimated by logistic regression in our study cohort provide further evidence that variables in published risk prediction scores are associated with rebound hyperbilirubinemia. Further studies are required to externally validate these risk prediction scores and to assess their generalizability.

Rooming-in for Infants at Risk for Neonatal Abstinence Syndrome: Outcomes 5 Years following Its Introduction as the Standard of Care at One Hospital.

OBJECTIVE: The practice of rooming-in for opioid-dependent infants was introduced as the standard of care at our hospital following a pilot study which demonstrated that such infants had shorter lengths of stay and were less likely to require pharmacological treatment. We sought to determine whether these benefits have continued, and whether outcomes support continuing to use rooming-in as standard care. STUDY DESIGN: Opioid-dependent infants delivered at 36 weeks gestation or later between January 1, 2015, and December 31, 2019, were eligible for rooming-in. Charts were reviewed and data were extracted regarding maternal and infant conditions, whether neonatal pharmacological treatment was required, and total length of hospital stay. Outcomes were compared with two historical groups reported in a previous pilot study: 24 healthy near-term opioid-dependent newborns who were admitted directly to the neonatal intensive care unit (NICU) prior to the introduction of rooming-in (May 1, 2012-May 31, 2013), and 20 similar opioid-dependent infants who were the first to room-in at our hospital (September 1, 2013-September 30, 2014). RESULTS: Only 3.5% of 57 infants who roomed-in during the 5-year study period required pharmacological treatment, compared with 15% who roomed-in during the first year of the program's introduction and 83.3% who had been admitted directly to the NICU. The median length of stay remained 5 days for infants rooming-in, compared with 24 days for opioid-dependent infants in the cohort admitted to the NICU. CONCLUSION: Early observations of the benefits of rooming-in on neonatal outcomes were sustained. Infants allowed to room-in were significantly less likely to require initiation of pharmacotherapy and a prolonged hospital stay than similar infants prior to the implementation of rooming-in as standard care. A large proportion of the infants who might have benefited from rooming-in required admission to the NICU for reasons other than neonatal abstinence syndrome (NAS). KEY POINTS: · Benefits of rooming-in for near-term opioid-dependent infants were sustained or increased.. · Rooming-in is sustainable as standard care for these newborns.. · Many infants required admission to NICU for reasons other than NAS..

Severe alcohol intoxication among Canadian Youth: A 2-year surveillance study.

PURPOSE: To obtain data on Canadian youth, aged 11 to 15 years, presenting to paediatric emergency departments, with severe alcohol intoxication and to describe demographics, presentations to hospital, concurrent substance use, comorbidities, and short-term outcomes of admission to emergency departments. METHODS: Between March 2013 and February 2015, through the established methodology of the Canadian Paediatric Surveillance Program, Canadian paediatricians and paediatric subspecialists were surveyed monthly to identify cases of young adolescents presenting to paediatric emergency departments across Canada with severe alcohol intoxication. Those that identified cases were subsequently sent a detailed questionnaire. The detailed questionnaires were then screened to ensure the reported cases met the study's inclusion criteria. RESULTS: A total of 39 cases (18 females and 21 males) were included in the final analysis. Overall, results indicate over 90% of presenting youth had consumed spirits, 39% had concurrent substance use and 46% experienced serious medical morbidity. Almost two-thirds of youth were admitted to hospital for a period ranging from 10 hours to 5 days; 12 youth required intubation. Follow-up referrals were provided to two-thirds of youth, with variable supports given. No statistically significant differences between sexes were noted for blood alcohol level or concurrent substance use. CONCLUSION: Although rates of alcohol use in adolescents have been steadily decreasing, results from this surveillance study suggest that severe intoxication arising from the use of alcohol alone, and with concurrent substance use, results in significant immediate health consequences in young adolescents. Results from this study also highlight characteristics of patients, initial treatments and initial referrals across Canadian paediatric healthcare facilities, the results of which highlight variability and may aid in the guidance of a future longitudinal study, prevention strategies, and public health messaging.

A national survey of the enteral feeding practices in Canadian neonatal intensive care units.

AIM: Nutrition affects the growth and neurodevelopmental outcomes of preterm infants, yet controversies exist about the optimal enteral feeding regime. The objective of this study was to compare enteral feeding guidelines in Canadian neonatal intensive care units (NICUs). METHOD: The research team identified key enteral feeding practices of interest. Canadian Neonatal Network site investigators at 30 Level 3 NICUs were contacted to obtain a copy of their 2016 to 2017 feeding guidelines for infants who weighed less than 1,500 g at birth. Each guideline was reviewed to compare recommendations around the selected feeding practices. RESULTS: Five of the 30 NICUs did not have a feeding guideline. The other 25 NICUs used 22 different enteral feeding guidelines. The guidelines in 40% of those NICUs recommend commencing minimal enteral nutrition (MEN) within 24 hours of birth and maintaining that same feeding volume for 24 to 96 hours. In 40% of NICUs, the guideline recommended that MEN be initiated at a volume of 5 to 10 mL/kg/day for infants born at <1,000 g. Guidelines in all 25 NICUs recommend the use of bovine-based human milk fortifier (HMF), and in 56% of NICUs, it is recommended that HMF be initiated at a total fluid intake of 100 mL/kg/day. Guidelines in only 16% of NICUs recommended routine gastric residual checks. Donor milk and probiotics are used in 76% and 72% of the 25 NICUs, respectively. CONCLUSION: This study revealed substantial variability in recommended feeding practices for very low birth weight infants, underscoring the need to establish a national feeding guideline for this vulnerable group.

Exploratory study of "real world" implementation of a clinical poverty tool in diverse family medicine and pediatric care settings.

BACKGROUND: Poverty is associated with increased morbidity related to multiple child and adult health conditions and increased risk of premature death. Despite robust evidence linking income and health, and some recommendations for universal screening, poverty screening is not routinely conducted in clinical care. METHODS: We conducted an exploratory study of implementing universal poverty screening and intervention in family medicine and a range of pediatric care settings (primary through tertiary). After attending a training session, health care providers (HCPs) were instructed to perform universal screening using a clinical poverty tool with the question "Do you ever have difficulty making ends meet at the end of the month?" for the three-month implementation period. HCPs tracked the number of patients screened and a convenience sample of their patients were surveyed regarding the acceptability of being screened for poverty in a healthcare setting. HCPs participated in semi-structured focus groups to explore barriers to and facilitators of universal implementation of the tool. RESULTS: Twenty-two HCPs (10 pediatricians, 9 family physicians, 3 nurse practitioners) participated and 150 patients completed surveys. Eighteen HCPs participated in focus groups. Despite the self-described motivation of the HCPs, screening rates were low (9% according to self-reported numbers). The majority of patients either supported (72%) or were neutral (22%) about the appropriateness of HCPs screening for and intervening on poverty. HCPs viewed poverty as relevant to clinical care but identified time constraints, physician discomfort, lack of expertise and habitual factors as barriers to implementation of universal screening. CONCLUSIONS: Poverty screening is important and acceptable to clinicians and patients. However, multiple barriers need to be addressed to allow for successful implementation of poverty screening and intervention in health care settings.

Interpregnancy Intervals in a Contemporary Manitoba Cohort: Prevalence of So-Called Suboptimal Intervals and Associated Maternal Characteristics.

OBJECTIVE: Short and long interpregnancy intervals (IPIs) have been associated with various adverse outcomes, and a 2016 American College of Obstetricians and Gynecologists' Committee Opinion recommends an optimal IPI of 18 months to 5 years. Descriptive data on the IPI in Canada are lacking. The objective of this study was to examine IPIs in a Manitoba cohort. METHODS: The study analyzed a subset of records from a larger dataset used to examine the IPI and adverse perinatal outcomes. For that study, Manitoba's Hospital Abstracts data were searched to identify births from 1985 to 2014. Each two consecutive live births to the same mother formed a sibling pair. The IPI was calculated as the interval between the two siblings' births, minus the younger sibling's GA. Information on maternal characteristics was extracted from various datasets housed in the Manitoba Population Research Data Repository. The current analysis examined second and higher-order births between 2010 and 2014. The proportion of suboptimal IPIs was determined and IPIs were cross-tabulated with birth year and maternal subgroups. RESULTS: More than half of pregnancies were conceived following a suboptimal interval. IPIs of less than 6 months - which have been associated with the highest risk of adverse outcomes - were more prevalent among certain subgroups. These included younger women as well as women who received inadequate prenatal care, smoked or drank alcohol during pregnancy, were low income, or did not graduate from high school. CONCLUSION: Suboptimal IPIs were common in this Manitoba cohort. Stakeholders should consider whether greater efforts to promote appropriate birth spacing are warranted.

Interpregnancy Interval and Congenital Anomalies: A Record-Linkage Study Using the Manitoba Population Research Data Repository.

OBJECTIVE: Congenital anomalies are a serious public health issue, and relatively few modifiable risk factors have been identified. Our objective was to investigate one such potential risk factor, the interpregnancy interval (IPI). METHODS: We conducted a secondary analysis of data housed at the Manitoba Centre for Health Policy. In-hospital live births and stillbirths of at least 20 weeks' gestation were identified, and consecutive births to the same mother were grouped into sibling pairs to calculate the IPI for the younger siblings of each pair. Logistic regression models were fit to examine the association between the IPI and any congenital anomaly, as well as CNS and chromosomal anomalies, while controlling for potentially confounding sociodemographic and clinical factors. RESULTS: Among 172 909 live births and stillbirths, the IPI was not significantly associated with congenital anomalies overall or with chromosomal anomalies. Short IPIs were associated with significantly increased odds of CNS anomalies relative to IPIs of 18-23 months (adjusted OR [aOR] for IPIs <6 months 2.15; 95% CI 1.48-3.12), whereas the aOR for IPIs ≥60 months was elevated but not statistically significant (aOR 1.50; 95% CI 0.96-2.34). In a sensitivity analysis in which the cohort was restricted to births from 2003 onwards (which yielded more complete data on health-related behaviours), the observed effect for IPIs shorter than 6 months and CNS anomalies was attenuated and no longer significant, but it remained elevated (aOR 1.65; 95% CI 0.85-3.24). CONCLUSION: The findings for CNS anomalies warrant further investigation.

Interpregnancy Interval and Adverse Perinatal Outcomes: A Record-Linkage Study Using the Manitoba Population Research Data Repository.

OBJECTIVE: To examine the association between the interpregnancy interval (IPI) and preterm birth, low birth weight, and SGA birth in a developed country with universal health coverage. METHODS: We conducted a secondary analysis of data housed at the Manitoba Centre for Health Policy. All live births in Manitoba hospitals over a 29-year period were identified and consecutive births to the same mother were grouped into sibling pairs to calculate the IPI for the younger siblings. Logistic regression models were fit to examine the association between the IPI and adverse perinatal outcomes, adjusted for potentially confounding sociodemographic and clinical factors. RESULTS: In a cohort of more than 171 000 births and relative to IPIs of 18 to 23 months, IPIs shorter than 12 and longer than 23 months were associated with significantly increased odds of preterm birth overall and both medically indicated and spontaneous preterm births, low birth weight, and SGA birth. The strongest association observed was for intervals shorter than 6 months and spontaneous preterm birth (adjusted OR 1.83, 95% CI 1.65-2.03). When the outcome was modelled as GA categories, the strongest association observed was for intervals shorter than 6 months and early preterm birth (<34 weeks' GA; adjusted OR 2.47, 95% CI 2.07-2.94). CONCLUSION: If the associations observed between the IPI and adverse perinatal outcomes in this large, population-based cohort are causal, birth spacing could form an important target of public health messaging in Canada.

Variations and similarities in clinical management of neonatal abstinence syndrome: Findings of a Canadian survey.

BACKGROUND: There are no evidence-based national guidelines for managing neonatal abstinence syndrome (NAS) and surveys from other countries have demonstrated considerable variations in practice. OBJECTIVE: To describe NAS management practices in Canada. METHOD: The directors of all Level 2 and Level 3 neonatal intensive care units (NICUs) were contacted to request their participation in a structured telephone survey. Frequency distributions were generated and associations between practice variations and unit type (Level 2 or 3) and size were examined. RESULTS: Personnel at 65 of 103 sites (63.1%) participated. Most (92.3%) stated their hospital has a written NAS practice guideline. The majority (89.5%) use a version of Finnegan's scoring system to monitor signs. If pharmacological treatment is required, 89.2% admit infants to the NICU and 93.8% routinely use cardiorespiratory monitors when treatment is initiated. Morphine is the first-line medication at most sites (96.9%). There was greater variability in terms of other practices: 44.6% observe at-risk infants in the NICU, while 52.3% allow them to room-in with their mothers; 65.1% use adjunct medications; 36.9% and 38.9% will discharge infants on the first-line and adjunct medications respectively, and 53.8% reported that breastfeeding is always encouraged, while 44.6% discourage breastfeeding if the mother continues to use illicit drugs and 1.5% make recommendations on an individual basis. Few practice variations were associated with unit type or size. CONCLUSION: While most NICUs surveyed have an NAS practice guideline, there are some notable differences in how NAS is managed. This underscores the need for research that can be translated into best practices.

Rooming-in for Infants at Risk of Neonatal Abstinence Syndrome.

OBJECTIVE: To examine the impact of a rooming-in program for infants at risk of neonatal abstinence syndrome (NAS) on the need for pharmacologic treatment and length of hospitalization. STUDY DESIGN: Our hospital implemented a rooming-in program for newborns at risk of NAS in June 2013. Previously, standard care was to admit these infants to the neonatal intensive care unit. Charts were reviewed to abstract data on at-risk infants born in the 13-month periods prior and subsequent to implementation of rooming-in (n = 24 and n = 20, respectively) and the groups were compared with the outcomes of interest. RESULT: Rooming-in was associated with a reduced need for pharmacologic treatment and shorter length of stay. CONCLUSION: These findings add to an emerging body of evidence on the health care resource utilization benefits associated with rooming-in for infants at risk of NAS. Future studies should evaluate a broader range of outcomes for this model of care.

Investigating Associations Between Nonadherence to Guideline-Recommended Treatment of Pediatric Seizures and Adverse Outcomes: A Canadian Feasibility Study.

BACKGROUND: Emerging evidence suggests that nonadherence to treatment guidelines for seizures may affect patient outcomes. We examined the feasibility of conducting a larger investigation to test this hypothesis in the pediatric population. METHODS: We retrospectively reviewed charts of patients aged ≤18 years who presented with seizure to the emergency departments of two Ontario hospitals in 2019 to 2021. Patients were grouped by seizure duration (<5 minutes [n = 37], ≥5 minutes [n = 41]). We examined nonadherence to guideline-recommended treatment, adverse outcomes (hospitalization, length of stay, respiratory complications), and missing values for key variables. RESULTS: Of 78 patients, 34 (44%) did not receive guideline-recommended treatment. Nonadherence was similar in the two groups (<5 minutes: 46%; ≥5 minutes: 41%). Common deviations included administering an antiseizure medication (ASM) for seizures of less than five minutes (46%), a delay (>10 minutes) between the first and second ASM doses (50%), and use of a benzodiazepine for the third dose (45%). Hospitalizations were common in both seizure duration groups (∼90%), whereas respiratory complications were relatively rare. Time of seizure onset was missing in 51% of charts, and none contained the time of first contact with emergency services when patients were transported by ambulance. CONCLUSION: We found evidence of substantial nonadherence to guideline-recommended treatment of pediatric seizures. Medical records do not contain sufficient information to comprehensively investigate this issue. A multicenter prospective study is the most feasible option to examine the association between nonadherence to guideline-recommended treatment and patient outcomes.

Celiac Disease and Inflammatory Bowel Disease Are Associated With Increased Risk of Eating Disorders: An Ontario Health Administrative Database Study.

INTRODUCTION: Previous national registry studies have reported an increased risk of eating disorders in immune-mediated conditions (inflammatory bowel disease and celiac disease). Our objective was to examine the association between immune-mediated gastrointestinal (GI) diseases and incident eating disorders in Ontario. METHODS: This was a retrospective matched cohort study of individuals <50 years of age with a diagnosis of an immune-mediated GI disease between 2002 and 2020 ("cases"). Those with a pre-existing eating disorder were excluded. Cases (n = 83,920) were matched with controls (n = 167,776) based on birth year, sex, and region of residence. Incidence rate ratio and hazard ratio were estimated using Poisson regression model and adjusted Cox proportional models, respectively. RESULTS: Over the follow-up period (up to January 31, 2022), 161 cases and 160 controls were identified with eating disorders. The overall incidence rate ratio (95% confidence interval, P -value) of eating disorders in immune-mediated GI disease was 1.99 (1.6-2.5, P < 0.001). The adjusted hazard ratio for eating disorder in cases with immune-mediated GI diseases was 1.98 (1.6-2.5, P < 0.001). In the pediatric group of incident cases (≤18 years of age), overall adjusted hazard ratio was 2.62 (1.9-3.7, P < 0.001) compared with 1.56 (1.02-2.4, P = 0.041) for adults (>18 years of age). The largest hazard ratio of 4.11 (1.6-10.3, P = 0.003) was observed for pediatric incident cases of ulcerative colitis. DISCUSSION: Inflammatory bowel disease and celiac disease are associated with the development of eating disorders. The magnitude of the association was stronger in the pediatric age group, underscoring the need for early screening and detection.

Variability in Emergency Management of Pediatric Diabetic Ketoacidosis.

OBJECTIVES: Our aim in this study was to identify pediatric patients presenting in diabetic ketoacidosis (DKA) who received initial treatment inconsistent with current guidelines and then to track associated complications. METHODS: This retrospective chart review examined 47 pediatric patients admitted to our institution with DKA, including those transferred from community hospitals. Primary outcome measures were exposure to treatment-related risk factors for cerebral edema (CE), including administration of an intravenous (IV) insulin bolus, IV bicarbonate, insulin within 1 hour of IV fluid start and non-NPO (nil per os) status. RESULTS: Seventy-five percent of patients were exposed to at least one management practice that deviated from guidelines. Thirty-four percent of patients were exposed to a treatment-related risk factor for CE, with a significantly higher prevalence in those presenting to community centres (52% vs 19%; p=0.02). There were no radiologically confirmed cases of CE. CONCLUSIONS: Despite the presence of multiple evidence-based guidelines, a significant proportion of children---and especially those who present to community centres---are exposed to practices that increase CE risk.

Comparison of Multivariable Logistic Regression and Machine Learning Models for Predicting Bronchopulmonary Dysplasia or Death in Very Preterm Infants.

Bronchopulmonary dysplasia (BPD) is the most prevalent and clinically significant complication of prematurity. Accurate identification of at-risk infants would enable ongoing intervention to improve outcomes. Although postnatal exposures are known to affect an infant's likelihood of developing BPD, most existing BPD prediction models do not allow risk to be evaluated at different time points, and/or are not suitable for use in ethno-diverse populations. A comprehensive approach to developing clinical prediction models avoids assumptions as to which method will yield the optimal results by testing multiple algorithms/models. We compared the performance of machine learning and logistic regression models in predicting BPD/death. Our main cohort included infants <33 weeks' gestational age (GA) admitted to a Canadian Neonatal Network site from 2016 to 2018 (n = 9,006) with all analyses repeated for the <29 weeks' GA subcohort (n = 4,246). Models were developed to predict, on days 1, 7, and 14 of admission to neonatal intensive care, the composite outcome of BPD/death prior to discharge. Ten-fold cross-validation and a 20% hold-out sample were used to measure area under the curve (AUC). Calibration intercepts and slopes were estimated by regressing the outcome on the log-odds of the predicted probabilities. The model AUCs ranged from 0.811 to 0.886. Model discrimination was lower in the <29 weeks' GA subcohort (AUCs 0.699-0.790). Several machine learning models had a suboptimal calibration intercept and/or slope (k-nearest neighbor, random forest, artificial neural network, stacking neural network ensemble). The top-performing algorithms will be used to develop multinomial models and an online risk estimator for predicting BPD severity and death that does not require information on ethnicity.

Multiple sclerosis: change in health-related quality of life over two years.

BACKGROUND: Cross-sectional research has demonstrated poorer function and health-related quality of life (HRQOL) in those with multiple sclerosis (MS) but less is known about change over time. The goals of this study were to measure change in HRQOL and identify factors associated with change. METHODS: HRQOL was assessed at baseline and annually over two subsequent years using the Multiple Sclerosis Quality of Life Inventory. Function was assessed using the Expanded Disability Status Scale (EDSS) and the Multiple Sclerosis Functional Composite. Annualized rate of change was calculated for all twenty outcomes. Mixed effects modeling (univariate followed by multivariate) was used to examine the associations among patient characteristics and the age- and sex-adjusted Physical Component Summary (PCS) and Mental Component Summary (MCS) at study initiation and over the two years of follow-up. RESULTS: Of 300 participants, 288 (96%) provided at least one assessment and are included in this analysis. Although 14 of the 20 outcomes showed a mean decline, only two (SF-36 physical function, p=0.018 and the EDSS, p<0.001) were statistically significant. The SF-36 social function showed a significant improvement (p=0.031). Only two variables were significantly associated with a decreased rate of decline or improvement over two years, including being female (PCS, p=0.001) and use of visiting nurse services (MCS, p<0.001). CONCLUSIONS: HRQOL is relatively stable over two years of follow-up, particularly for mentally-oriented outcomes. Further research with a longer period of follow-up is needed to provide additional insight into factors associated with change in HRQOL in patients with MS.

Age at diagnosis of autism spectrum disorders in four regions of Canada.

OBJECTIVES: Early diagnosis of autism spectrum disorders ("autism") may lead to better treatment outcomes, reduces the stress parents experience when they do not understand the reasons for their child's behaviour, and empowers parents to make choices such as seeking genetic counseling. We examined the age at which Canadian children are diagnosed with autism, and analyzed whether there are geographic or temporal variations or differences by sex or diagnostic subtype. METHODS: As part of an autism surveillance program, in 2002/2003 we began collecting information on children with autism in Manitoba, Southeastern Ontario, Prince Edward Island, and Newfoundland and Labrador. For the analysis presented in this paper, we included children identified for our surveillance program who were diagnosed between 1997 and 2005 (n = 769). RESULTS: We found significant inter-regional differences in age at diagnosis, with Newfoundland and Labrador having the lowest median age at diagnosis (39.0 months) and Southeastern Ontario the highest (55.0 months). Diagnostic subtype was significantly associated with age at diagnosis in all regions. Southeastern Ontario was the only region where the overall age at diagnosis increased over time (p = 0.004), although in Manitoba the age at which children were diagnosed with PDD-NOS also increased significantly over the study period (p = 0.021). CONCLUSIONS: Our findings demonstrate that there are geographic differences and other sources of variation in the age at which Canadian children are diagnosed with autism. Further study is warranted to understand the factors contributing to these differences. Such research would inform best practices for early detection and timely access to treatment.

Are observed associations between a high maternal prepregnancy body mass index and offspring IQ likely to be causal?

BACKGROUND: A high maternal prepregnancy body mass index has been associated with lower offspring IQ, but it is unclear if the relationship is causal. To explore this, our objectives were to compare maternal and paternal estimates and to assess whether certain factors mediate the association. METHODS: We analysed data from the Avon Longitudinal Study of Parents and Children, which initially recruited 14 541 women residing in Avon, UK, with an expected date of delivery in 1991-1992. Data were collected during and after pregnancy by questionnaire, medical record abstraction and clinical assessment. At approximately 8 years of age, psychologists administered an abbreviated form of the Wechsler Intelligence Scale for Children-III. We fit multivariable logistic regression models to estimate parental prepregnancy obesity and overweight-offspring IQ associations. Counterfactually defined indirect (mediated) effects of maternal prepregnancy obesity on offspring IQ were estimated through path analysis. RESULTS: Among 4324 mother-father-child triads and using normal weight as the referent, we observed consistently stronger associations for maternal prepregnancy obesity and offspring performance IQ (eg, adjusted ß (95% CI)=-3.4 (-5.7 to -1.2) vs -0.97 (-2.9 to 0.96) for paternal obesity). The indirect effects of maternal obesity on offspring IQ through pathways involving gestational weight gain and duration of breastfeeding were small but significant. CONCLUSION: Our findings are consistent with a weak biologic effect of maternal adiposity in pregnancy on offspring performance IQ. Given the growing prevalence of obesity worldwide, more evidence is needed to resolve the correlation versus causation debate in this area.

Trends in autism prevalence: diagnostic substitution revisited.

There has been little evidence to support the hypothesis that diagnostic substitution may contribute to increases in the administrative prevalence of autism. We examined trends in assignment of special education codes to British Columbia (BC) school children who had an autism code in at least 1 year between 1996 and 2004, inclusive. The proportion of children with an autism code increased from 12.3/10,000 in 1996 to 43.1/10,000 in 2004; 51.9% of this increase was attributable to children switching from another special education classification to autism (16.0/10,000). Taking into account the reverse situation (children with an autism code switching to another special education category (5.9/10.000)), diagnostic substitution accounted for at least one-third of the increase in autism prevalence over the study period.