The impact of daycare attendance on outdoor free play in young children.

Background: Outdoor free play is important for healthy growth and development in early childhood. Recent studies suggest that the majority of time spent in daycare is sedentary. The objective of this study was to determine whether there was an association between daycare attendance and parent-reported outdoor free play. Methods: Healthy children aged 1-5 years recruited to The Applied Research Group for Kids! (TARGet Kids!), a primary care research network, were included. Parents reported daycare use, outdoor free play and potential confounding variables. Multivariable linear regression was used to determine the association between daycare attendance and outdoor free play, adjusted for age, sex, maternal ethnicity, maternal education, neighborhood income and season. Results: There were 2810 children included in this study. Children aged 1 to <3 years (n = 1388) and ≥3 to 5 years (n = 1284) who attended daycare had 14.70 min less (95% CI -20.52, -8.87; P < 0.01) and 9.44 min less (95% CI -13.67, -5.20; P < 0.01) per day of outdoor free play compared with children who did not attend daycare, respectively. Conclusions: Children who spend more time in daycare have less parent-reported outdoor free play. Parents may be relying on daycare to provide opportunity for outdoor free play and interventions to promote increased active play opportunities outside of daycare are needed.

The concurrent and longitudinal associations of temperament and nutritional risk factors in early childhood.

BACKGROUND: Early childhood temperament is increasingly recognized as an important attribute that may impact screen time use, outdoor play and childhood obesity. The relationship between temperament and nutrition in preschool children is less clear. OBJECTIVE: The objective of the study is to investigate if temperament dimensions (negative affectivity, effortful control and surgency) in early childhood are associated with nutritional risk factors. METHODS: Six hundred seventy-eight children were followed (mean age at baseline visit 3.1 years; mean time to follow-up 16.5 months). Parents reported on child temperament and nutritional risk factors during regularly scheduled well-child clinic visits. RESULTS: A mixed effect model demonstrated a significant association between higher negative affectivity (1.03; 95% CI 0.69 to 1.37) and higher effortful control (-0.88; 95% CI -1.27 to -0.49) on concurrent nutritional risk, independent of covariates. Multivariate linear regression analysis identified that higher effortful control, and not negative affectivity, was significantly associated with a decrease in nutritional risk (-0.67; 95% CI -1.10 to -0.24) over time, independent of covariates. There was no relationship identified between surgency and nutritional risk. CONCLUSION: Three-year-old children with higher effortful control had reduced nutritional risk at 5 years of age. Future nutritional risk prevention strategies may benefit from interventions to increase effortful control in early childhood.

Vitamin D exposure during pregnancy, but not early childhood, is associated with risk of childhood wheezing.

The association between vitamin D and wheezing in early childhood is unclear. The primary objective of this study was to evaluate the association between vitamin D exposure, during both pregnancy and childhood, and early childhood wheezing. Secondary objectives were to evaluate the associations between vitamin D exposures and asthma and wheezing severity. We conducted a cohort study of children (0-5 years) recruited from 2008 to 2013 through the TARGet Kids! primary-care research network. Vitamin D exposures included maternal vitamin D supplement use during pregnancy, child vitamin D supplementation and children's 25-hydroxyvitamin D (25(OH)D) concentrations. The outcomes measured were parent-reported childhood wheezing, diagnosed asthma and wheezing severity. Vitamin D supplement and wheezing data were available for 2478 children, and blood samples were available for 1275 children. Adjusted odds ratios (aOR) were estimated using logistic regression adjusted for age, sex, ethnicity, body mass index, birth weight, outdoor play, breastfeeding duration, daycare status, parental smoking and family history of asthma. Vitamin D supplementation during pregnancy was associated with lower odds of childhood wheezing (aOR=0.65; 95% CI: 0.46-0.93). In early childhood, neither 25(OH)D (aOR per 10 nmol/l=1.01; 95% CI: 0.96-1.06) nor vitamin D supplementation (aOR=1.00; 95% CI: 0.81-1.23) was associated with wheezing. No significant associations were observed with diagnosed asthma or wheezing severity. Vitamin D supplementation during pregnancy was associated with reduced odds of wheezing, but child vitamin D supplementation and childhood 25(OH)D were not associated with reduced wheezing. The timing of exposure may be important in understanding the association between vitamin D and childhood wheezing.

Canadian parents' attitudes and beliefs about bicycle helmet legislation in provinces with and without legislation.

INTRODUCTION: The objective of this study was to survey Canadian parents on their attitudes and beliefs about bicycle helmet legislation and to compare responses from parents living in provinces with and without legislation. METHODS: A national survey of 1002 parents of children aged under 18 years was conducted. Chi-square tests were used to compare responses from the surveyed parents in the different jurisdictions. RESULTS: Responses from parents living in provinces with legislation (n = 640) and without legislation (n = 362) were as follows: concern for injury (63% vs. 68%, nonsignificant [NS]); believe helmets are effective (98% vs. 98%, NS); child always wears a helmet (74% vs. 69%, NS); support legislation for children (95% vs. 83%, p < .001); support legislation for all ages (85% vs. 75%, p < .001); support police enforcement (83% vs. 76%, p = .003); believe legislation decreases the amount of time their child bicycles (5% vs. 8%, NS). CONCLUSION: Parents are highly supportive of bicycle helmet legislation in Canada. They believe that bicycle helmets are effective and that legislation does not decrease the amount of time a child spends bicycling. There was also a high level of support for legislation across all ages, and for police enforcement.

TITRE: Attitudes et croyances des parents au sujet du port obligatoire du casque de vélo : comparaison entre provinces avec et sans législation. INTRODUCTION: L'objectif de l'étude était d'effectuer un sondage auprès de parents canadiens sur leurs attitudes et leurs croyances au sujet de la législation du port du casque chez les cyclistes et de comparer les réponses des parents vivant dans une province ayant légiféré dans ce domaine et celles de ceux vivant dans une province n'ayant pas légiféré. MÉTHODOLOGIE: Un sondage national a été réalisé auprès de 1 002 parents d'enfants âgés de moins de 18 ans. Des tests du chi-carré ont été utilisés pour comparer les réponses des parents dans les différentes provinces. RÉSULTATS: Les réponses des parents vivant dans une province ayant légiféré (n = 640) ou ne l'ayant pas fait (n = 362) s'établissent respectivement comme suit : sont préoccupés par les accidents de vélo (63 % et 68 %, non significatif [NS]); croient que le port du casque de vélo est une mesure efficace (98 % et 98 %, NS); l'enfant porte toujours un casque de vélo (74 % et 69 %, NS); sont favorables à une loi visant les enfants (95 % et 83 %, p < 0,001); sont favorables à une loi visant les cyclistes de tous âges (85 % et 75 %, p < 0,001); sont favorables à l'application de la loi par les services de police (83 % et 76 %, p = 0,003); croient que la loi réduit la durée d'utilisation de la bicyclette par leur enfant (5 % et 8 %, NS). CONCLUSION: Les parents sont largement favorables à la législation du port du casque chez les cyclistes au Canada. Ils croient que le casque de vélo est une mesure efficace et que la loi n'a pas pour effet de réduire la durée d'utilisation de la bicyclette par leur enfant. Ils sont également largement favorables à une loi visant les cyclistes de tous âges et à l'application de la loi par les services de police.

Increasing incidence of ALS in Canterbury, New Zealand: a 22-year study.

OBJECTIVE: We performed a prospective study of amyotrophic lateral sclerosis (ALS) in North Canterbury, New Zealand, from 1985 to 2006, to ascertain the incidence of ALS over that 22-year period, and to detect patterns of change in incidence. We also aimed to identify factors that influenced survival. METHODS: A prospective database of all patients seen at the Department of Neurology at Christchurch Public Hospital formed the basis of this study. Additional cases were identified through hospital coding data and from neurologists' private practice records. Kaplan-Meier life table analysis and Cox proportional hazards analyses were used for the survival analysis. Poisson regression and capture-recapture techniques were used to analyze incidence data. RESULTS: ALS incidence rates steadily increased by 3% per year over the 22 years, from 1.6 to 3.3 per 100,000 per year. Older age, bulbar symptoms, and male sex adversely affected survival. The median survival from diagnosis was 17.6 months and from symptom onset 27.6 months. Contemporary supportive therapies such as noninvasive ventilation and percutaneous endoscopic gastrostomy did not extend survival. There was no disease clustering and no clues to etiology were revealed. CONCLUSIONS: We report the highest recorded incidence of amyotrophic lateral sclerosis (ALS) to date, with the incidence of ALS in Canterbury increasing over the 22 years of the study. We were unable to confirm improvement in survival using contemporary supportive therapies and confirmed older age, male sex, and bulbar onset as adverse prognostic factors. The increasing incidence is not explained by aging of the population.

Economic disparity in bicycle helmet use by children six years after the introduction of legislation.

BACKGROUND: Studies evaluating the effectiveness of bicycle helmet legislation often focus on short term outcomes. The long term effect of helmet legislation on bicycle helmet use is unknown. OBJECTIVE: To examine bicycle helmet use by children six years after the introduction of the law, and the influence of area level family income on helmet use. METHODS: The East York (Toronto) health district (population 107,822) was divided into income areas (designated as low, mid, and high) based on census tract data from Statistics Canada. Child cyclists were observed at 111 preselected sites (schools, parks, residential streets, and major intersections) from April to October in the years 1995-1997, 1999, and 2001. The frequency of helmet use was determined by year, income area, location, and sex. Stratified analysis was used to quantify the relation between income area and helmet use, after controlling for sex and bicycling location. RESULTS: Bicycle helmet use in the study population increased from a pre-legislation level of 45% in 1995 to 68% in 1997, then decreased to 46% by 2001. Helmet use increased in all three income areas from 1995 to 1997, and remained above pre-legislation rates in high income areas (85% in 2001). In 2001, six years post-legislation, the proportion of helmeted cyclists in mid and low income areas had returned to pre-legislation levels (50% and 33%, respectively). After adjusting for sex and location, children riding in high income areas were significantly more likely to ride helmeted than children in low income areas across all years (relative risk = 3.4 (95% confidence interval, 2.7 to 4.3)). CONCLUSION: Over the long term, the effectiveness of bicycle helmet legislation varies by income area. Alternative, concurrent, or ongoing strategies may be necessary to sustain bicycle helmet use among children in mid and low income areas following legislation.

Identification of vigilance lapses using EEG/EOG by expert human raters.

It is critically important for certain occupational groups to remain highly alert throughout their working day. For safety reasons, it would be useful to automatically detect lapses in performance using EEG/EOG. Automating the detection process could be simplified considerably if we could mimic human experts. Surprisingly, it is unclear to what extent human EEG raters are able to detect lapses. Consequently, we undertook a study in which 4 expert EEG raters assessed the level of alertness of 10 air traffic controllers by observing a combination of their EEG and EOG while they performed a 10 min psychomotor vigilance task (PVT). They were specifically required to identify lapses or sleep episodes that might lead to a lapse in PVT performance. A reaction time .. 500 ms was defined as a PVT lapse. There was a total of 101 lapses (mean duration = 1.00 s). Of these, only 6 lapses were detected by one or more raters and all of these were marked as ;sleep'. Overall the human expert raters were unable to reliably identify lapses based only on EEG and EOG. This poor performance suggests an automated system would need to identify subtle features not overtly visible in the EEG.

Community paediatricians' counseling patterns and knowledge of recommendations relating to child restraint use in motor vehicles.

BACKGROUND: Road traffic injury is the leading cause of death among Canadian children and youth. Transport Canada recommends four types of child restraint depending on the size of the child, and recent studies have demonstrated the effectiveness of recommended restraint use. OBJECTIVES: To determine community paediatricians' knowledge of Transport Canada recommendations for child restraint use in vehicles, and to examine paediatricians' counseling patterns in relation to child passenger safety. METHODS: A mailed questionnaire survey of all community paediatricians affiliated with the Hospital for Sick Children, Toronto was conducted. A 16 item questionnaire gathered information on knowledge of Transport Canada recommendations for child restraint use, general counseling patterns in relation to child passenger safety, and demographic information. RESULTS: In total, 60 community paediatricians in active practice were identified. Of these, 48 (80%) responded to the mailed questionnaire. Almost all paediatricians (92%) correctly identified the recommended weight for transition to a forward-facing car seat, whereas fewer paediatricians (63%) correctly identified the recommended weight for transition to a booster seat from a forward-facing car seat, and only one third of paediatricians correctly identified the recommended weight for transition from a booster seat to a seat belt. CONCLUSION: Community paediatricians' knowledge of Transport Canada recommendations for child restraint use in vehicles is incomplete. There is a need for such recommendations to be better disseminated to paediatricians and parents so that information on child restraint use is delivered in a clear and consistent manner.

Rapid painless diagnosis of viral respiratory infection.

The concordance of nasal compared with nasopharyngeal swabs was assessed for the diagnosis of respiratory viral infections, and the degree of discomfort associated with each procedure was compared. The use of nasal swabs was shown to be as accurate but significantly less painful than nasopharyngeal swabs for virus diagnosis.

Randomized trial of the addition of ipratropium bromide to albuterol and corticosteroid therapy in children hospitalized because of an acute asthma exacerbation.

OBJECTIVE: To determine whether the addition of inhaled ipratropium bromide to inhaled albuterol and systemic corticosteroid therapy was more efficacious than inhaled albuterol and systemic corticosteroids alone in the inpatient treatment of acute asthma exacerbations in children. DESIGN: Double-blind, randomized, placebo-controlled trial. SETTING: Pediatric inpatient unit of a tertiary urban hospital. PARTICIPANTS: Eighty children (aged 1-18 years) hospitalized because of an acute asthma exacerbation. INTERVENTION: Children were randomized to receive either nebulized ipratropium bromide, 250 microg, or nebulized isotonic sodium chloride solution, 1 mL. All children received albuterol and systemic corticosteroids. MAIN OUTCOME MEASURES: The primary outcome variable was a validated clinical asthma score, measured at baseline and every 6 hours for 36 hours. Secondary outcome measures included the forced expiratory volume in 1 second, the oxygen saturation, the number of doses of inhaled study drug, the time to an inhaled drug-dosing interval of 4 hours, and the length of the hospital stay. RESULTS: There were no differences between groups on baseline characteristics. The intention-to-treat analysis, using repeated-measures analysis of variance, showed no significant (P =.07) difference between the groups in the clinical asthma score over time. There were also no significant differences between groups on secondary outcomes. CONCLUSION: The addition of nebulized ipratropium bromide to nebulized beta(2)-agonist and corticosteroid therapy in the treatment of children hospitalized because of asthma (following intensive emergency department treatment) confers no extra benefit.

Mandatory helmet legislation and children's exposure to cycling.

BACKGROUND: Mandatory helmet legislation for cyclists is the subject of much debate. Opponents of helmet legislation suggest that making riders wear helmets will reduce ridership, thus having a negative overall impact on health. Mandatory bicycle helmet legislation for children was introduced in Ontario, Canada in October 1995. The objective of our study was to examine trends in children's cycling rates before and after helmet legislation in one health district. SETTING: Child cyclists were observed at 111 preselected sites (schools, parks, residential streets, and major intersections) in the late spring and summer of 1993-97 and in 1999, in a defined urban community. PARTICIPANTS: Trained observers counted the number of child cyclists. The number of children observed in each area was divided by the number of observation hours, resulting in the calculation of cyclists per hour. MAIN OUTCOME MEASURE: A general linear model, using Tukey's method, compared the mean number of cyclists per hour for each year, and for each type of site. RESULTS: Although the number of child cyclists per hour was significantly different in different years, these differences could not be attributed to legislation. In 1996, the year after legislation came into effect, average cycling levels were higher (6.84 cyclists per hour) than in 1995, the year before legislation (4.33 cyclists per hour). CONCLUSION: Contrary to the findings in Australia, the introduction of helmet legislation did not have a significant negative impact on child cycling in this community.

Predictors of hospitalization in children with acute asthma.

OBJECTIVE: To identify predictors of long duration of bronchodilator therapy in children with acute asthma. STUDY DESIGN: An emergency department prospective cohort study of 278 children > or =12 months of age, with clinical and socioeconomic parameters collected at baseline and 4 hours after administration of corticosteroids. Patients were classified into short and long therapy groups, with interval from first albuterol dose to initiation of administration every 4 hours < or =12 or >12 hours, respectively. Predictors significant by univariate analysis were examined by multiple logistic regression. RESULTS: Five variables were associated with long therapy (n = 85) versus short therapy (n = 193): previous intensive care unit admission (odds ratio [OR] 7.2, 95% CI = 1.85, 27.7); baseline oxygen saturation < or =92% (OR 2.6, 95% CI = 0.89, 7.4), asthma score > or =6/9 (OR 2.9, 95% CI = 1.9, 4.37), oxygen saturation < or =92% (OR 6.6, 95% CI = 1.34, 32.0), and hourly albuterol dosing interval (OR 4.3, 95% CI = 0.82, 22.12) 4 hours after administration of corticosteroids. Probability of long therapy was 91.8% to 99% for > or =3 predictors, but only 40.6% to 61.8% for individual factors. CONCLUSION: A combination of 3 or more factors predicts long bronchodilator therapy and signals the need for hospitalization. Children with only one predictor can be safely treated in the emergency department or observation unit and reevaluated.

Assessing the efficacy of a school-based asthma education program for children: a pilot study.

BACKGROUND: Asthma diminishes the health-related quality of life for many school-aged children. This study sought to explore the effect of a School-Based Asthma Education Program (SBAEP) on quality of life. METHODS: Children with asthma who attended grades 1-5 at two selected schools were requested to participate in this pilot study. Participants at one school were provided with a SBAEP, those at another school (control group) were provided with written educational material about asthma. The children completed the Paediatric Asthma Quality of Life Questionnaire (PAQLQ) before and one month after the educational interventions. RESULTS: There were clinically important improvements in the SBAEP group in quality of life, specifically in the symptom subdomain. CONCLUSIONS: The "Air Force" SBAEP appears to result in a favourable trend in quality of life for children. A larger scale trial is required following revisions to the program.

Childhood asthma admissions: determinants of short stay.

The objective of this study was to identify the determinants of short hospital stay (< 24 h) among children admitted because of an acute asthma exacerbation. Computerized health records were used to identify children with a discharge diagnosis of asthma (ICD code 493.0) at the Hospital for Sick Children, Toronto, during the period October 1994 to October 1995. Cases were children with a length of hospital stay of < 24 h (short-stay group) and controls were children with a length of stay of > 24 h (long-stay group). Clinical and demographic data were extracted from the medical record. Over the 12-month period, 485 children were hospitalized because of asthma. Of these, 121 (25%) had short-stay admissions (< 24 h), whereas 364 (75%) had long-stay admissions (> 24 h). Simple random sampling was used to select 85 children from each of the two groups. There were no differences between the two groups regarding language, primary care physician, asthma history, management prior to emergency department (ED) presentation, respiratory rate on presentation, use of the observation unit, and time in the ED. Logistic regression analyses identified three variables associated with short hospital stay: milder asthma (adjusted odds ratio [OR] 4.9), male gender (adjusted OR 2.4), and availability of a delivery device at home (adjusted OR 2.0). In conclusion, many children admitted to hospital because of an asthma exacerbation have short, yet expensive, hospital stays. The results of this study highlight the importance of developing alternative models of health care delivery for asthmatic children requiring short hospital contact.

Quality of life in spina bifida: importance of parental hope.

BACKGROUND AND AIMS: Prognosis in spina bifida (SB) is often based only on neurological deficits present at birth. We hypothesised that both parental hope and the neurophysical examination predict quality of life in children and adolescents with SB. METHODS: A previously validated disease and age specific health related quality of life (HRQL) instrument was posted to families of children (aged 5-12 years) and adolescents (aged 13-20 years) with SB. We measured parental hope, determined the child's current physical function, and obtained retrospective data on the neonatal neurophysical examination (NPE). Regression analysis modelled HRQL firstly as a dependent variable on parental hope and NPE ("birth status"); and secondly on parental hope and current physical function ("current function"). RESULTS: Response rates were 71% (137 of 194) for families of children, and 54% (74 of 138) for families of adolescents. NPE data were available for 121 children and 60 adolescents. In children, the birth status model predicted 26% of the variability (R(2) hope 21%) compared with 23% of the variability (R(2) hope 23%)in the adolescents. The current function model explained 47% of the variability (R(2) hope 19%) in children compared with 31% of the variability (R(2) hope 24%) in the adolescents. CONCLUSIONS: In both age groups, parental hope was more strongly associated with the HRQL than neonatal or current physical deficits. A prospective study is required to determine whether a causal relation exists between parental hope and HRQL of children and adolescents with SB.

Real-time detection of epileptiform activity in the EEG: a blinded clinical trial.

The aim of this study was to determine the performance of a PC-based system for real-time detection and topographical mapping of epileptiform activity (EA) in the EEG during routine clinical recordings. The system incorporates a mimetic stage to locate candidate spikes (including sharp-waves) followed by two expert-system-based stages, which utilize spatial and wide-temporal contextual information in deciding whether candidate events are epileptiform or not. The data comprised 521 consecutive routine clinical EEG recordings (173 hours). Performance was evaluated by comparison with three independent electroencephalographers (EEGers-I). A second group of two EEGers (EEGers-II) separately interpreted the spike topographical maps and, for EEGs categorized as containing only questionable EA by the detection system, reviewed 6 sec segments of raw EEG centered on each questionable event. Thirty-eight of the EEGs were considered to contain definite EA by at least two of EEGers-I. The false detection rate of the system was 0.41 per hour. The system was found to have a sensitivity of 76% and a selectivity of 41% for EEGs containing definite EA. However, it only missed detection of EA in 5% of the recordings. EEGers-II agreed with EEGers-I on the distribution (generalized, lateralized, focal, multifocal) of EA in 79% of cases. This is by far the largest clinical evaluation of computerized spike detection reported in the literature and the only one to apply this in routine clinical recordings. The false detection rate is the lowest ever reported, suggesting that this multi-stage rule-based system is a powerful and practical tool in clinical electroencephalography and long-term EEG monitoring.

Brain stem stroke causing baroreflex failure and paroxysmal hypertension.

BACKGROUND: Paroxysmal neurogenic hypertension has been associated with a variety of diseases affecting the brain stem but has only rarely been reported after brain stem stroke. The mechanism is thought to involve increased sympathetic activity and baroreflex dysfunction. We undertook microneurographic recordings of muscle sympathetic nerve activity (MNSA) during beat-to-beat blood pressure (BP) monitoring to investigate this hypothesis. CASE DESCRIPTION: We investigated a 75-year-old woman who developed paroxysmal hypertension (BP 220/110 mm Hg) after a large left-sided medullary infarct. The paroxysms were triggered by changes in posture and were accompanied by tachycardia, diaphoresis, and headache. Serum catecholamines were substantially increased (norepinephrine level, 23.9 nmol/L 9 days after stroke; normal level, <3.8 nmol/L), and heart rate variability, measured by spectral analysis, was decreased in both low- and high-frequency domains (0.04 and 0.06 ms(2), respectively; normal level, 0.14+/-0.02 ms(2)). MNSA was increased in frequency (61 bursts per minute; normal level, 34+/-18 bursts per minute), and the burst amplitude was not inversely related to diastolic BP. BP and MNSA responses to cold pressor and isometric handgrip stimuli were intact. CONCLUSIONS: Extensive unilateral infarction of the brain stem in the region of the nucleus tractus solitarius may result in partial baroreflex dysfunction, increased sympathetic activity, and neurogenic paroxysmal hypertension.