Post-COVID-19 Condition in Children.

This cohort study assesses the parent-reported incidence and resolution of post­COVID-19 symptoms among children aged 8 to 13 years.

Association of COVID-19 Government-Instituted Mask Mandates With Incidence of Mask Use Among Children in Alberta, Canada.

Importance: To help prevent the spread of SARS-CoV-2, government-instituted nonpharmaceutical interventions (eg, social distancing, mask use, isolating), a provincewide government-instituted mask mandate occurred on December 8, 2020, in Alberta, Canada, although some local jurisdictions implemented an earlier mask mandate. There remains a limited understanding of the association between government-implemented public health measures and individual health behaviors of children. Objective: To examine the association between government mask mandates and mask use among children in Alberta, Canada. Design, Setting, and Participants: A cohort of children from Alberta, Canada, was recruited to examine longitudinal SARS-CoV-2 serologic factors. Parents were prospectively asked about their child's mask use in public places every 3 months (5-point Likert scale: never to always) from August 14, 2020, to June 24, 2022. A multivariable logistic generalized estimating equation was used to examine government mandatory masking mandates and child mask use. Child mask use was operationalized into a single composite dichotomous outcome by grouping parents who reported their child often or always wore a mask vs those who reported their child never, rarely, or occasionally wore a mask. Exposures: The primary exposure variable was the government masking mandate (began on different dates in 2020). The secondary exposure variable was government private indoor and outdoor gathering restrictions. Main Outcomes and Measures: The primary outcome was parent report of child mask use. Results: A total of 939 children participated (467 female [49.7%]; mean [SD] age, 10.61 [1.6] years). The odds of parents' report of child mask use (often or always) was 18.3 times higher (95% CI, 5.7-58.6; P < .001; risk ratio, 1.7; 95% CI, 1.5-1.8; P < .001) with the mask mandate on compared with the mask mandate off. There was no significant change in mask use over the course of the mask mandate due to time. In contrast, each day with the mask mandate off was associated with a 1.6% decrease in mask use (odds ratio, 0.98; 95% CI, 0.98-0.99; P < .001). Conclusions and Relevance: The results of this study suggest that government-mandated mask use and providing the public with up-to-date health information (eg, case counts) is associated with increased parent-reported child mask use, while increasing time without a mask mandate is associated with decreased mask use.

Influence of Neighborhood Characteristics and Weather on Movement Behaviors at Age 3 and 5 Years in a Longitudinal Birth Cohort.

BACKGROUND: Movement behaviors (physical activity, sedentary time, and sleep) established in early childhood track into adulthood and interact to influence health outcomes. This study examined the associations between neighborhood characteristics and weather with movement behaviors in preschoolers. METHODS: A subset of Canadian Healthy Infant Longitudinal Development birth cohort (n = 385, 50.6% boys) with valid movement behaviors data were enrolled at age 3 years and followed through to age 5 years. Objective measures of neighborhood characteristics were derived by ArcGIS software, and weather variables were derived from the Government of Canada weather website. Random forest and linear mixed models were used to examine predictors of movement behaviors. Cross-sectional analyses were stratified by age and season (winter and nonwinter). RESULTS: Neighborhood safety, temperature, green space, and roads were important neighborhood characteristics for movement behaviors in 3- and 5-year-olds. An increase in temperature was associated with greater light physical activity longitudinally from age 3 to 5 years and also in the winter at age 5 years in stratified analysis. A higher percentage of expressways was associated with less nonwinter moderate to vigorous physical activity at age 3 years. CONCLUSIONS: Future initiatives to promote healthy movement behaviors in the early years should consider age differences, neighborhood characteristics, and season.

Development and Validation of SDBeasy Score as a Predictor of Behavioral Outcomes in Childhood.

Rationale: There are limited tools to identify which children are at greatest risk for developing sleep-disordered breathing (SDB)-associated behavioral morbidity.Objectives: To examine associations between age of onset and duration of parent-reported symptoms of SDB and behavioral problems at the age of 5 years.Methods: Data were collected and analyses were completed for participants in the CHILD (Canadian Healthy Infant Longitudinal Development) cohort at the Edmonton and Toronto sites. We generated an SDBeasy score on the basis of the age of onset and duration of SDB symptoms as reported by parents completing the Pediatric Sleep Questionnaire. Using CHILD-Edmonton data, we completed multivariate linear regression to determine whether the SDBeasy score was associated with behavioral problems at the age 5 years of age as assessed by using the Child Behavior Checklist (CBCL). We then validated the SDBeasy score using CHILD-Toronto data.Measurements and Main Results: At the 5-year visit, 581 of 716 (81%) CHILD-Edmonton participants still enrolled had CBCL data. Of the 581 children with data, 77% (446 of 581) had an SDBeasy score of 0 (never had SDB symptoms), whereas 20 of 581 children (3.4%) had persistent SDB symptoms from infancy through 5 years of age (SDBeasy score of 24). Children had a 0.35-point-higher CBCL total behavioral score at 5 years for each 1-point increase in their SDBeasy score (95% confidence interval, 0.24-0. 5; P < 0.01). We found consistent results among CHILD-Toronto participants; children had a 0.26-point-higher CBCL total behavioral score at 5 years for each 1-point increase in their SDBeasy score (95% confidence interval, 0.08-0.44; P = 0.005).Conclusions: The SDBeasy score, based on the Pediatric Sleep Questionnaire, enables identification of children with higher behavioral-problem scores.

The relationship between machine-learning-derived sleep parameters and behavior problems in 3- and 5-year-old children: results from the CHILD Cohort study.

STUDY OBJECTIVES: Machine learning (ML) may provide insights into the underlying sleep stages of accelerometer-assessed sleep duration. We examined associations between ML-sleep patterns and behavior problems among preschool children. METHODS: Children from the CHILD Cohort Edmonton site with actigraphy and behavior data at 3-years (n = 330) and 5-years (n = 304) were included. Parent-reported behavior problems were assessed by the Child Behavior Checklist. The Hidden Markov Model (HMM) classification method was used for ML analysis of the accelerometer sleep period. The average time each participant spent in each HMM-derived sleep state was expressed in hours per day. We analyzed associations between sleep and behavior problems stratified by children with and without sleep-disordered breathing (SDB). RESULTS: Four hidden sleep states were identified at 3 years and six hidden sleep states at 5 years using HMM. The first sleep state identified for both ages (HMM-0) had zero counts (no movement). The remaining hidden states were merged together (HMM-mov). Children spent an average of 8.2 ± 1.2 h/day in HMM-0 and 2.6 ± 0.8 h/day in HMM-mov at 3 years. At age 5, children spent an average of 8.2 ± 0.9 h/day in HMM-0 and 1.9 ± 0.7 h/day in HMM-mov. Among SDB children, each hour in HMM-0 was associated with 0.79-point reduced externalizing behavior problems (95% CI -1.4, -0.12; p < 0.05), and a 1.27-point lower internalizing behavior problems (95% CI -2.02, -0.53; p < 0.01). CONCLUSIONS: ML-sleep states were not associated with behavior problems in the general population of children. Children with SDB who had greater sleep duration without movement had lower behavioral problems. The ML-sleep states require validation with polysomnography.

Screen-time is associated with inattention problems in preschoolers: Results from the CHILD birth cohort study.

BACKGROUND: Pre-school children spend an average of two-hours daily using screens. We examined associations between screen-time on pre-school behavior using data from the Canadian Healthy Infant Longitudinal Development (CHILD) study. METHODS: CHILD participant parents completed the Child Behavior Checklist (CBCL) at five-years of age. Parents reported their child's total screen-time including gaming and mobile devices. Screen-time was categorized using the recommended threshold of two-hours/day for five-years or one-hour/day for three-years. Multiple linear regression examined associations between screen-time and externalizing behavior (e.g. inattention and aggression). Multiple logistic regression identified characteristics of children at risk for clinically significant externalizing problems (CBCL T-score≥65). RESULTS: Screen-time was available for over 95% of children (2,322/2,427) with CBCL data. Mean screen-time was 1·4 hours/day (95%CI 1·4, 1·5) at five-years and 1·5 hours/day (95%CI: 1·5, 1·6) at three-years. Compared to children with less than 30-minutes/day screen-time, those watching more than two-hours/day (13·7%) had a 2·2-point increase in externalizing T-score (95%CI: 0·9, 3·5, p≤0·001); a five-fold increased odd for reporting clinically significant externalizing problems (95%CI: 1·0, 25·0, p = 0·05); and were 5·9 times more likely to report clinically significant inattention problems (95%CI: 1·6, 21·5, p = 0·01). Children with a DSM-5 ADHD T-score above the 65 clinical cut-off were considered to have significant ADHD type symptoms (n = 24). Children with more than 2-hours of screen-time/day had a 7·7-fold increased risk of meeting criteria for ADHD (95%CI: 1·6, 38·1, p = 0·01). There was no significant association between screen-time and aggressive behaviors (p>0.05). CONCLUSION: Increased screen-time in pre-school is associated with worse inattention problems.

Associations between meeting the Canadian 24-Hour Movement Guidelines for the Early Years and behavioral and emotional problems among 3-year-olds.

OBJECTIVES: Primary: examine associations between meeting the 24-Hour Movement Guidelines for the Early Years and behavioral and emotional problems in a large sample of 3-year-old children. Secondary: determine the proportion of children meeting the Canadian 24-Hour Movement Guidelines. DESIGN: Cross-sectional. METHODS: Participants were 3-year olds (n=539) from the Edmonton site of the Canadian Healthy Infant Longitudinal Development (CHILD) birth cohort. Physical activity and sleep duration were accelerometer-derived while screen time was parent-reported. Meeting the overall guidelines was defined as: (1) ≥180min/day of total physical activity, including 60min/day of moderate- to vigorous-intensity physical activity, (2) ≤1h/day of screen time, and (3) 10-13h of sleep per 24-hour period. Externalizing, internalizing, and total problem scores (lower scores representing fewer problems) were calculated from the parent-reported Child Behavior Checklist (CBCL). Descriptive statistics and linear regression models were completed. RESULTS: Only 5% of children met the overall guidelines (all three recommendations), with 19.3%, 50.5%, and 83.1% meeting the physical activity, screen time, and sleep recommendations, respectively. Meeting more recommendations was associated with lower scores for total (B=-1.78, 95%CI: -3.03, -0.54), externalizing (B=-1.51, 95%CI: -2.80, -0.22) and internalizing (B=-1.35, 95%CI: -2.60, -0.01) problems. Similar findings were also observed for the specific combinations of: (1) physical activity and screen time and (2) sleep duration and screen time. CONCLUSIONS: Meeting more recommendations within the 24-hour Movement Guidelines was associated with fewer behavioral and emotional problems at 3-years. Few 3-year-olds met the overall guidelines. Findings support an integrated approach for healthy growth and development.

Shorter sleep duration is associated with reduced cognitive development at two years of age.

BACKGROUND: Both short sleep duration and sleep-disordered breathing (SDB) are associated with poor neurocognitive development. However, the co-contributions of short sleep duration and SDB on neurodevelopment in pre-school children are relatively unknown. METHODS: We assessed both sleep duration and SDB by quarterly questionnaire from three months to two years of age among Canadian Healthy Infant Longitudinal Development (CHILD) birth cohort participants. Group-based modeling determined trajectories of total, daytime, and nighttime sleep duration and SDB. Linear regression was used to assess the impact of sleep duration and SDB trajectories on cognitive (primary outcome) and language (secondary) development at two years of age as assessed by the Bayley Scale of Infant Development (BSID-III) (mean 100; standard deviation of 15). RESULTS: Of the 822 CHILD Edmonton participants, 703 (86%) were still enrolled at two years of age with 593 having BSID-III data at two years of age. Trajectory analysis identified four total sleep durations phenotypes [short sleepers (17.9%), decline to short sleepers (21.1%), intermediate sleepers (36.9%) and long sleepers (24.1%)]. Compared to children with intermediate sleep durations, short sleepers had a 5.2-point lower cognitive development score at two years of age [standard error (SE) 1.7; p = 0.002]. Nocturnal sleep duration, compared to daytime sleep duration had the greatest effect on cognitive development. We also identified three SDB symptom trajectories [early-onset SDB (15.7%), late-onset SDB (14.2%), and persistent SDB (5.3%)] and 79.5% of children had no SDB symptoms. Children with persistent SDB also had a 5.3-point lower language score (SE 2.7; p = 0.05) compared to children with no SDB. SDB trajectories were not associated with cognitive development. CONCLUSION: In a population-representative birth cohort study, both short sleep duration and SDB were associated with adverse neurodevelopment at two years of age. Children with short nighttime sleep duration had lowered cognitive and language scores and children with persistent SDB also had lower language scores.

Phenotypes of sleep-disordered breathing symptoms to two years of age based on age of onset and duration of symptoms.

OBJECTIVE: Childhood sleep-disordered breathing (SDB) symptoms may comprise multiple phenotypes depending on craniofacial anatomy, tonsil and adenoid growth, body habitus, and rhinitis symptoms. The primary objective of this study is to identify and characterize the different SDB phenotypes to two years of age. METHODS: Data from 770 infants in the Edmonton sub-cohort of the Canadian Healthy Infant Longitudinal Study (CHILD) were analyzed to identify SDB phenotypes based on age of onset and duration of symptoms. Parents completed the 22-item sleep-related breathing disorder (SRBD) scale. Children with a SRBD ratio greater than 0.33 were considered positive for SDB at each quarterly assessment between three months and two years. The STATA Proc trajectory extension identified SDB phenotypes based on their age of onset and duration of symptoms and attributed the percentage chance of a participant being assigned to each phenotype. Multivariate linear regression identified factors associated with increased risk of being assigned to each SDB phenotype. RESULTS: Trajectory analysis identified four phenotypes: no SDB (65.7%), early-onset SDB (15.7%) with peak symptoms at nine months, late-onset SDB (14.2%) with peak symptoms at 18 months, and persistent SDB (5.3%) with symptoms from 3 to 24 months. Rhinitis was associated with all three SDB symptom trajectories (p < 0.05). Children with gastroesophageal reflux disease presented with early (p = 0.03) and late SDB (p < 0.001). Maternal obstructive sleep apnea syndrome (OSAS) was associated with persistent (p = 0.01) and late SDB (p < 0.001). Atopy (positive skin prick test at one year) was associated with persistent SDB (p = 0.04). Infants born prior to 36.5 weeks gestational age were more likely to present with late SDB (p = 0.03). CONCLUSION: Childhood SDB symptoms, rather than being a homogenous disorder, may comprise multiple overlapping phenotypes each with unique risk factors.

Parent-Reported Symptoms of Sleep-Disordered Breathing Are Associated With Increased Behavioral Problems at 2 Years of Age: The Canadian Healthy Infant Longitudinal Development Birth Cohort Study.

Study Objectives: To examine the association between the age of onset and duration of parent-reported symptoms of sleep-disordered breathing (SDB) and behavioral problems at age 2. Methods: Parent-reported SDB symptoms were assessed quarterly between 3 months and 2 years among 583 Canadian Healthy Infant Longitudinal Development Edmonton-site participants. Parent-reported SDB symptoms were clustered into phenotypes using group-based trajectory analysis based on age of onset and duration of symptoms. Home-based polysomnography (PSG) was completed at 1 year. The Child Behavior Checklist preschool-version (Mean T-score 50, standard deviation 10 points) assessed total, externalizing (attention), and internalizing (anxiety, depression) behaviors at 2 years. Results: Four phenotypes were identified: no SDB (64.7%), early-onset SDB (15.7%, peak symptoms at 9 months), late-onset (14.2%, peak symptoms at 18 months), and persistent SDB symptoms (5.3%, peak symptoms from 3 through 24 months). Persistent SDB (9.5 points, 95% CI 1.7, 17.2; p = .02) predicted the greatest magnitude of effect of total behavior problems, compared with children without SDB. Children with early-onset SDB (3.5 points, 95% CI 1.6, 5.4; p ≤ .001) and late-onset SDB (6.1 points 95% CI 4.0, 8.3; p ≤ .001) had increased total behavioral problems than children without SDB to 2 years. Additional analyses showed that the SDB phenotypes' trajectories were important for internalizing but not for externalizing behavior problems. There were no significant associations between home-PSG and parent-reported behavior problems. Conclusions: Findings suggest that the age of onset and duration of parent-reported SDB symptoms prior to age 2 have adverse consequences for overall behavior problems.