Mode of delivery and birth outcomes before and during COVID-19 -A population-based study in Ontario, Canada.

There is lack of clarity on whether pregnancies during COVID-19 resulted in poorer mode of delivery and birth outcomes in Ontario, Canada. We aimed to compare mode of delivery (C-section), birth (low birthweight, preterm birth, NICU admission), and health services use (HSU, hospitalizations, ED visits, physician visits) outcomes in pregnant Ontario women before and during COVID-19 (pandemic periods). We further stratified for pre-existing chronic diseases (asthma, eczema, allergic rhinitis, diabetes, hypertension). Deliveries before (Jun 2018-Feb 2020) and during (Jul 2020-Mar 2022) pandemic were from health administrative data. We used multivariable logistic regression analyses to estimate adjusted odds ratios (aOR) of delivery and birth outcomes, and negative binomial regression for adjusted rate ratios (aRR) of HSU. We compared outcomes between pre-pandemic and pandemic periods. Possible interactions between study periods and covariates were also examined. 323,359 deliveries were included (50% during pandemic). One in 5 (18.3%) women who delivered during the pandemic had not received any COVID-19 vaccine, while one in 20 women (5.2%) lab-tested positive for COVID-19. The odds of C-section delivery during the pandemic was 9% higher (aOR = 1.09, 95% CI: 1.08-1.11) than pre-pandemic. The odds of preterm birth and NICU admission were 15% (aOR = 0.85, 95% CI: 0.82-0.87) and 10% lower (aOR = 0.90, 95% CI: 0.88-0.92), respectively, during COVID-19. There was a 17% reduction in ED visits but a 16% increase in physician visits during the pandemic (aRR = 0.83, 95% CI: 0.81-0.84 and aRR = 1.16, 95% CI: 1.16-1.17, respectively). These aORs and aRRs were significantly higher in women with pre-existing chronic conditions. During the pandemic, healthcare utilization, especially ED visits (aRR = 0.83), in pregnant women was lower compared to before. Ensuring ongoing prenatal care during the pandemic may reduce risks of adverse mode of delivery and the need for acute care during pregnancy.

Policies in Canada fail to address disparities in access to person-centred osteoarthritis care: a content analysis.

BACKGROUND: Women are disproportionately impacted by osteoarthritis (OA) but less likely than men to access OA care, particularly racialized women. One way to reduce inequities is through policies that can influence healthcare services. We examined how OA-relevant policies in Canada address equitable, person-centred OA care for women. METHODS: We used content analysis to extract data from English-language OA-relevant documents referred to as policies or other synonymous terms published in 2000 or later identified by searching governmental and other web sites. We used summary statistics to describe policy characteristics, person-centred care using McCormack's six-domain framework, and mention of OA prevalence, barriers and strategies to improve equitable access to OA care among women. RESULTS: We included 14 policies developed from 2004 to 2021. None comprehensively addressed all person-centred care domains, and few addressed individual domains: enable self-management (50%), share decisions (43%), exchange information (29%), respond to emotions (14%), foster a healing relationship (0%) and manage uncertainty (0%). Even when mentioned, content offered little guidance for how to achieve person-centred OA care. Few policies acknowledged greater prevalence of OA among women (36%), older (29%) or Indigenous persons (29%) and those of lower socioeconomic status (14%); or barriers to OA care among those of lower socioeconomic status (50%), in rural areas (43%), of older age (37%) or ethno-cultural groups (21%), or women (21%). Four (29%) policies recommended strategies for improving access to OA care at the patient (self-management education material in different languages and tailored to cultural norms), clinician (healthcare professional education) and system level (evaluate OA service equity, engage lay health leaders in delivering self-management programs, and offer self-management programs in a variety of formats). Five (36%) policies recommended research on how to improve OA care for equity-seeking groups. CONCLUSIONS: Canadian OA-relevant policies lack guidance to overcome disparities in access to person-centred OA care for equity-seeking groups including women. This study identified several ways to strengthen policies. Ongoing research must identify the needs and preferences of equity-seeking persons with OA, and evaluate the impact of various models of service delivery, knowledge needed to influence OA-relevant policy.

Association of empiric antibiotic selection and clinical outcomes in hospitalised children with severe orbital infections: a retrospective cohort study.

OBJECTIVE: To determine the association of initial empiric antibiotic regimens with clinical outcomes in hospitalised children with severe orbital infections. DESIGN: Multi-centre observational cohort study using data from 2009 to 2018 clinical records. SETTING: Canadian children's hospitals (7) and community hospitals (3). PATIENTS: Children between 2 months and 18 years hospitalised for >24 hours with severe orbital infections. INTERVENTIONS: Empiric intravenous antibiotic regimen in the first 24 hours of hospitalisation. MAIN OUTCOME MEASURES: Length of hospital stay and surgical intervention using multivariable median regression and multivariate logistic regression, with adjustment for covariates. RESULTS: Of 1421 patients, 60.0% were male and the median age was 5.5 years (IQR 2.4-9.9). Median length of stay was 86.4 hours (IQR 56.9-137.5) and 180 (12.7%) received surgical intervention. Patients receiving broad-spectrum empiric antibiotics had an increased median length of stay, ranging from an additional 13.8 hours (third generation cephalosporin and anaerobic coverage) to 19.5 hours (third generation cephalosporin, staphylococcal and anaerobic coverage). No antibiotic regimen was associated with a change in the odds of surgical intervention. These findings remained unchanged in sensitivity analyses restricted to more severely ill patients. There was a twofold increase in the percentage of patients receiving the broadest empiric antibiotic regimens containing both staphylococcal and anaerobic coverage from 17.8% in 2009 to 40.3% in 2018. CONCLUSIONS: Empiric use of broad-spectrum antibiotics with staphylococci and anaerobic coverage was associated with longer length of stay and similar rates of surgery in children with orbital infections. There is an urgent need for comparative effectiveness studies of various antibiotic regimes.

Sociodemographic Factors and Trends in Bronchiolitis-Related Emergency Department Visit and Hospitalization Rates.

Importance: Bronchiolitis is the most common and most cumulatively expensive condition in pediatric hospital care. Few population-based studies have examined health inequalities in bronchiolitis outcomes over time. Objective: To examine trends in bronchiolitis-related emergency department (ED) visit and hospitalization rates by sociodemographic factors in a universally funded health care system. Design, Setting, and Participants: This repeated cross-sectional cohort study was performed from April 1, 2004, to March 31, 2022, using population-based health administrative data from children younger than 2 years in Ontario, Canada. Main Outcome and Measures: Bronchiolitis ED visit and hospitalization rates per 1000 person-years reported for the equity stratifiers of sex, residence location (rural vs urban), and material resources quintile. Trends in annual rates by equity stratifiers were analyzed using joinpoint regression and estimating the average annual percentage change (AAPC) with 95% CI and the absolute difference in AAPC with 95% CI from April 1, 2004, to March 31, 2020. Results: Of 2 921 573 children included in the study, 1 422 088 (48.7%) were female and 2 619 139 (89.6%) lived in an urban location. Emergency department visit and hospitalization rates were highest for boys, those with rural residence, and those with least material resources. There were no significant between-group absolute differences in the AAPC in ED visits per 1000 person-years by sex (female vs male; 0.22; 95% CI, -0.92 to 1.35; P = .71), residence (rural vs urban; -0.31; 95% CI -1.70 to 1.09; P = .67), or material resources (quintile 5 vs 1; -1.17; 95% CI, -2.57 to 0.22; P = .10). Similarly, there were no significant between-group absolute differences in the AAPC in hospitalizations per 1000 person-years by sex (female vs male; 0.53; 95% CI, -1.11 to 2.17; P = .53), residence (rural vs urban; -0.62; 95% CI, -2.63 to 1.40; P = .55), or material resources (quintile 5 vs 1; -0.93; 95% CI -3.80 to 1.93; P = .52). Conclusions and Relevance: In this population-based cohort study of children in a universally funded health care system, inequalities in bronchiolitis ED visit and hospitalization rates did not improve over time.

Association of factors with childhood asthma and allergic diseases using latent class analysis.

We hypothesize that children characterized by deprived factors have poorer health outcomes. We aim to identify clustering of determinants and estimate risk of early childhood diseases. This 1993-2019 longitudinal cohort study combines three Canadian pediatric cohorts and their families. Mothers and children are clustered using latent class analysis (LCA) by 16 indicators in three domains (maternal and newborn; socioeconomic status [SES] and neighbourhood; environmental exposures). Hazard ratios (HR) of childhood asthma, allergic rhinitis (AR), and eczema are quantified with Cox proportional hazard (PH) regression. Rate ratios (RR) of children's health services use (HSU) are estimated with Poisson regression. Here we report the inclusion of 15,724 mother-child pairs; our LCA identifies four mother-clusters. Classes 1 and 2 mothers are older (30-40 s), non-immigrants with university education, living in high SES neighbourhoods; Class 2 mothers have poorer air quality and less greenspace. Classes 3 and 4 mothers are younger (20-30 s), likely an immigrant/refugee, with high school-to-college education, living in lower SES neighborhoods with poorer air quality and less greenspace. Children's outcomes differ by Class, in comparison to Class 1. Classes 3 and 4 children have higher risks of asthma (HR 1.24, 95% CI 1.11-1.37 and HR 1.39, 95% CI 1.22-1.59, respectively), and similar higher risks of AR and eczema. Children with AR in Class 3 have 20% higher all-cause physician visits (RR = 1.20, 95% CI 1.10-1.30) and those with eczema have 18% higher all-cause emergency department visits (RR = 1.18, 95% CI 1.09-1.28) and 14% higher all-cause physician visits (RR = 1.14, 95% CI 1.09-1.19). Multifactorial-LCA mother-clusters may characterize associations of children's health outcomes and care, adjusting for interrelationships.

Connecting families: a qualitative study examining the experiences of parenting young children under financial strain in Ontario, Canada.

BACKGROUND: There is little research investigating the subjective experiences of parenting young children while living in poverty and experiencing financial strain using qualitative methodologies. Therefore, the objective of this study was to employ a qualitative approach to provide a nuanced and balanced view on the topic of parenting young children under financial strain in the Canadian context. METHODS: We conducted a qualitative study using semi-structured interviews between July and August 2021 in Kingston, Ontario, Canada. Sixteen participants aged 20-39 self-identified as living under financial strain while parenting a child aged 2-5 years. A qualitative inductive thematic analysis was undertaken with a focus on describing the contents of the data. RESULTS: Four major themes emerged from the data: experience of being a parent, impact of financial strain on the family unit, impact of financial strain on the children, and impact of financial strain on the parent. Numerous deleterious physical, mental, and material impacts on the family unit and parent were identified, however parent-perceived impacts of financial strain on their children were minimal. Parents described striking levels of resourcefulness and resiliency in providing the necessities for their families, absorbing the most significant impacts of financial strain through the phenomenon of self-sacrifice. CONCLUSION: The impacts of financial strain on families with young children are far reaching. Further research into the impacts of self-sacrifice on parents experiencing financial strain are needed to better understand this issue, and to inform social programming and resources that could help alleviate the deleterious impacts of poverty on parent mental, social, and physical health.

Haemoglobin thresholds to define anaemia from age 6 months to 65 years: estimates from international data sources.

BACKGROUND: Detection of anaemia is crucial for clinical medicine and public health. Current WHO anaemia definitions are based on statistical thresholds (fifth centiles) set more than 50 years ago. We sought to establish evidence for the statistical haemoglobin thresholds for anaemia that can be applied globally and inform WHO and clinical guidelines. METHODS: In this analysis we identified international data sources from populations in the USA, England, Australia, China, the Netherlands, Canada, Ecuador, and Bangladesh with sufficient clinical and laboratory information collected between 1998 and 2020 to obtain a healthy reference sample. Individuals with clinical or biochemical evidence of a condition that could reduce haemoglobin concentrations were excluded. We estimated haemoglobin thresholds (ie, 5th centiles) for children aged 6-23 months, 24-59 months, 5-11 years, and 12-17 years, and adults aged 18-65 years (including during pregnancy) for individual datasets and pooled across data sources. We also collated findings from three large-scale genetic studies to summarise genetic variants affecting haemoglobin concentrations in different ancestral populations. FINDINGS: We identified eight data sources comprising 18 individual datasets that were eligible for inclusion in the analysis. In pooled analyses, the haemoglobin fifth centile was 104·4 g/L (90% CI 103·5-105·3) in 924 children aged 6-23 months, 110·2 g/L (109·5-110·9) in 1874 children aged 24-59 months, and 114·4 g/L (113·6-115·2) in 1839 children aged 5-11 years. Values diverged by sex in adolescents and adults. In pooled analyses, the fifth centile was 122·2 g/L (90% CI 121·3-123·1) in 1741 female adolescents aged 12-17 years and 128·2 g/L (126·4-130·0) in 1103 male adolescents aged 12-17 years. In pooled analyses of adults aged 18-65 years, the fifth centile was 119·7 g/L (90% CI 119·1-120·3) in 3640 non-pregnant females and 134·9 g/L (134·2-135·6) in 2377 males. Fifth centiles in pregnancy were 110·3 g/L (90% CI 109·5-111·0) in the first trimester (n=772) and 105·9 g/L (104·0-107·7) in the second trimester (n=111), with insufficient data for analysis in the third trimester. There were insufficient data for adults older than 65 years. We did not identify ancestry-specific high prevalence of non-clinically relevant genetic variants that influence haemoglobin concentrations. INTERPRETATION: Our results enable global harmonisation of clinical and public health haemoglobin thresholds for diagnosis of anaemia. Haemoglobin thresholds are similar between sexes until adolescence, after which males have higher thresholds than females. We did not find any evidence that thresholds should differ between people of differering ancestries. FUNDING: World Health Organization and the Bill & Melinda Gates Foundation.

Association of ever use of e-cigarettes with health and lifestyle variables among young adults: a Canadian health measure survey study.

Research suggests that vaping raises oxidative stress levels and has been implicated in poor mental health. The objective of this study is to assess cross-sectional associations between quality of life (QOL) indicators and e-cigarette (EC) use in young Canadian adults. We used data from the 2016-2017 Canadian Health Measures Survey. We compared physical activity (daily steps), physiological measurements (high-density lipoprotein for cholesterol level), self-perceived life stress, mental health, and QOL between ever-use EC users and non-users. Multivariable binary or ordinal logistic regressions were used to calculate odds ratios (OR) with 95% confidence intervals (CI). Analyses included 905 participants (15-30 years) with 115 (12.7%) reporting EC use and 790 non-users. After adjusting for confounders, compared to non-users, EC users had significantly higher odds of being physically active (OR = 2.19, 95%CI: 1.14-4.20) but also with self-reported extreme life stress (OR = 2.68, 95%CI: 1.45-4.92). Albeit statistically non-significant, EC users also had higher odds of poorer QOL (OR = 1.12, 95%CI: 0.64-1.95). No statistically significant interactions between EC use, cigarette smoking, cannabis consumption and health outcomes were observed. CONCLUSION: Our study found that EC use was independently and significantly associated with increased odds of life stress and an indication of poorer QOL. Ongoing surveillance on young EC users is important to measure the long-term impact of vaping on their physical, mental health and quality of life to target for interventions. WHAT IS KNOWN: • E-cigarette use has been associated with high-risk behaviours and adverse mental health outcomes, such as depression and anxiety. WHAT IS NEW: • E-cigarette users had significantly higher odds of being physically active and higher amounts of life stress.

Priority strategies to reduce socio-gendered inequities in access to person-centred osteoarthritis care: Delphi survey.

OBJECTIVES: Osteoarthritis (OA) prevalence, severity and related comorbid conditions are greater among women compared with men, but women, particularly racialised women, are less likely than men to access OA care. We aimed to prioritise strategies needed to reduce inequities in OA management. DESIGN: Delphi survey of 28 strategies derived from primary research retained if at least 80% of respondents rated 6 or 7 on a 7-point Likert scale. SETTING: Online. PARTICIPANTS: 35 women of diverse ethno-cultural groups and 29 healthcare professionals of various specialties from across Canada. RESULTS: Of the 28 initial and 3 newly suggested strategies, 27 achieved consensus to retain: 20 in round 1 and 7 in round 2. Respondents retained 7 patient-level, 7 clinician-level and 13 system-level strategies. Women and professionals agreed on all but one patient-level strategy (eg, consider patients' cultural needs and economic circumstances) and all clinician-level strategies (eg, inquire about OA management needs and preferences). Some discrepancies emerged for system-level strategies that were more highly rated by women (eg, implement OA-specific clinics). Comments revealed general support among professionals for system-level strategies provided that additional funding or expanded scope of practice was targeted to only formally trained professionals and did not reduce funding for professionals who already managed OA. CONCLUSIONS: We identified multilevel strategies that could be implemented by healthcare professionals, organisations or systems to mitigate inequities and improve OA care for diverse women.

Young Infants Clinical Signs Study 8-sign Algorithm for Identification of Sick Infants Adapted for Routine Home Visits: A Systematic Review and Critical Appraisal of its Measurement Properties.

Objective. The 8-sign algorithm adapted from the Young Infants Clinical Signs Study (YICSS) is widely used to identify sick infants during home visits (YICSS-home algorithm). We aimed to critically appraise the development and evidence of measurement properties, including sensibility, reliability, and validity, of the YICSS-home algorithm. Methods. Relevant studies were identified through a systematic literature search. Results. The YICSS-home algorithm has good sensibility. The algorithm demonstrated at least moderate inter-rater reliability and sensitivity ranging from 69% to 80%. However, the algorithm was developed among sick infants brought for care to a health facility and not initially developed for use by community health workers (CHWs) during home visits. Some important risk factors were omitted at item generation. Inter-CHW reliability and construct validity have not been estimated. Conclusion. Future research should build on the strengths of the YICSS-home algorithm and address its limitations to develop a new algorithm with improved predictive accuracy.

Hemoglobin Threshold for Blood Transfusion in Young Children Hospitalized with Iron Deficiency Anemia.

Current recommendations advise against blood transfusion in hemodynamically stable children with iron deficiency anemia. In an observational study of 125 children aged 6 through 36 months, hospitalized with iron deficiency anemia, we found that hemoglobin level predicted red blood cell transfusion (area under the curve 0.8862). A hemoglobin of 39 g/L had sensitivity 92% and specificity 72% for transfusion.

Association Between Family Income and Positive Developmental Screening Using the Infant Toddler Checklist at the 18-Month Health Supervision Visit.

OBJECTIVE: To examine the associations between several potential predictors (child biologic, social, and family factors) and a positive screen for developmental delay using the Infant Toddler Checklist (ITC) at the 18-month health supervision visit in primary care. METHODS: This was a cross-sectional study of healthy children attending an 18-month health supervision visit in primary care. Parents completed a standardized questionnaire, addressing child, social, and family characteristics, and the ITC. Logistic regression analyses were used to assess the associations between predictors and a positive ITC. RESULTS: Among 2188 participants (45.5% female; mean age, 18.2 months), 285 (13%) had a positive ITC and 1903 (87%) had a negative ITC. The aOR for a positive ITC for male compared with female sex was 2.15 (95% CI, 1.63-2.83; P < .001). The aOR for birthweight was 0.65 per 1 kg increase (95% CI, 0.53-0.80; P < .001). The aOR for a family income of <$40,000 compared with ≥$150,000 was 3.50 (95% CI, 2.22-5.53; P < .001), and the aOR for family income between $40,000-$79,999 compared with ≥$150,000 was 1.88 (95% CI, 1.26-2.80; P = .002). CONCLUSIONS: Screening positive on the ITC may identify children at risk for the double jeopardy of developmental delay and social disadvantage and allow clinicians to intervene through monitoring, referral, and resource navigation for both child development and social needs. TRIAL REGISTRATION: Clinicaltrials.gov (NCT01869530).

Defining quality of preventive oral health services in a northern First Nations community: a concept mapping study.

INTRODUCTION: In partnership with the Norway House Cree Nation (NHCN) in Manitoba, Canada, this study developed a framework based on how Indigenous parents/caregivers of young children and community-based oral health decision-makers perceive 'quality of preventive oral health services'. METHODS: Concept mapping was used to develop the 'quality of preventive oral health services' framework. This involved brainstorming/idea generation, sorting and rating, visual representation, and interpretation sessions with parents/caregivers (CG) and decision-makers (DM) in Norway House, Manitoba. Using the Concept System's GlobalMax software, a conceptual framework was created that was modified from input from CG and DM groups, which can be visualized through the concept map. RESULTS: The final concept map revealed seven domains of quality preventive oral health services: dental staff character and skills, working with community, responsibilities in preventive education, inclusive preventive oral health strategies, accessibility to appointments, logistics of providing services, and dental environment. CONCLUSION: This study provides insight into the existing gap in oral health services for Indigenous populations. Based on conversations and the concept mapping process, the developed framework can inform the steps to be taken to improve preventive oral health services for Indigenous peoples. The framework has been used to develop a quantitative scale to inform sustainable and impactful change in the quality of preventive oral health services that are meaningful to Indigenous peoples.

Multi-level strategies to improve equitable timely person-centred osteoarthritis care for diverse women: qualitative interviews with women and healthcare professionals.

BACKGROUND: Women are more likely to develop osteoarthritis (OA), and have greater OA pain and disability compared with men, but are less likely to receive guideline-recommended management, particularly racialized women. OA care of diverse women, and strategies to improve the quality of their OA care is understudied. The purpose of this study was to explore strategies to overcome barriers of access to OA care for diverse women. METHODS: We conducted qualitative interviews with key informants and used content analysis to identify themes regarding what constitutes person-centred OA care, barriers of OA care, and strategies to support equitable timely access to person-centred OA care. RESULTS: We interviewed 27 women who varied by ethno-cultural group (e.g. African or Caribbean Black, Chinese, Filipino, Indian, Pakistani, Caucasian), age, region of Canada, level of education, location of OA and years with OA; and 31 healthcare professionals who varied by profession (e.g. family physician, nurse practitioner, community pharmacist, physio- and occupational therapists, chiropractors, healthcare executives, policy-makers), career stage, region of Canada and type of organization. Participants within and across groups largely agreed on approaches for person-centred OA care across six domains: foster a healing relationship, exchange information, address emotions, manage uncertainty, share decisions and enable self-management. Participants identified 22 barriers of access and 18 strategies to overcome barriers at the patient- (e.g. educational sessions and materials that accommodate cultural norms offered in different languages and formats for persons affected by OA), healthcare professional- (e.g. medical and continuing education on OA and on providing OA care tailored to intersectional factors) and system- (e.g. public health campaigns to raise awareness of OA, and how to prevent and manage it; self-referral to and public funding for therapy, greater number and ethno-cultural diversity of healthcare professionals, healthcare policies that address the needs of diverse women, dedicated inter-professional OA clinics, and a national strategy to coordinate OA care) levels. CONCLUSIONS: This research contributes to a gap in knowledge of how to optimize OA care for disadvantaged groups including diverse women. Ongoing efforts are needed to examine how best to implement these strategies, which will require multi-sector collaboration and must engage diverse women.

Screening Accuracy of the Parent-Report Preschool Strengths and Difficulties Questionnaire in Primary Care.

OBJECTIVE: To evaluate the screening test accuracy and reliability of the parent-report preschool Strengths and Difficulties Questionnaire (P-SDQ) in primary care settings. METHODS: Children 24 to 48 months were recruited at scheduled primary care visits in Toronto, Canada. Parents completed the P-SDQ at baseline, 2, and 12 weeks. At 12 weeks, parents were invited to a semistructured diagnostic phone interview, the Preschool Age Psychiatric Assessment (PAPA). Criterion validity between baseline P-SDQ scores (Total Difficulties Score [TDS], internalizing and externalizing subscale) and Diagnostic and Statistical Manual, 5th edition diagnoses on PAPA was evaluated using area under the curve (AUC) and calculating screening test properties (sensitivity and specificity). Test-retest reliability at baseline and 2 weeks was evaluated using intraclass correlation coefficient. RESULTS: A total of 183 children were enrolled, mean age 39.3 (SD 7.4) months, 46.4% male, 120 (66%) completed P-SDQ at 2 weeks, 107 (58%) completed PAPA at 12 weeks. Of those with a PAPA, 26 (24%) had any psychiatric diagnosis, 17 (16%) had internalizing disorders and 4 (4%) had externalizing disorders. TDS identified any diagnosis with AUC = 0.67 (95% confidence intervals (CI): 0.55, 0.79); internalizing subscale identified internalizing disorders with AUC = 0.61 (95% CI: 0.47, 0.74); externalizing subscale identified externalizing disorders with AUC = 0.77 (95% CI: 0.60, 0.94). Sensitivity and specificity, and test-retest reliability were satisfactory for TDS and externalizing subscale, and less satisfactory for the internalizing subscale. CONCLUSIONS: The externalizing subscale has sufficient accuracy and reliability to identify children aged 2 to 4 years at risk for attention deficit/hyperactivity disorder and disruptive behavior disorders in primary care.

Late preterm birth and growth trajectories during childhood: a linked retrospective cohort study.

BACKGROUND: Evidence suggests that accelerated postnatal growth in children is detrimental for adult cardiovascular health. It is unclear whether children born late preterm (34-36 weeks) compared to full term (≥ 39 weeks), have different growth trajectories. Our objective was to evaluate the association between gestational age groups and growth trajectories of children born between 2006-2014 and followed to 2021 in Ontario, Canada. METHODS: We conducted a retrospective cohort study of children from singleton births in TARGet Kids! primary care network with repeated measures of weight and height/length from birth to 14 years, who were linked to health administrative databases. Piecewise linear mixed models were used to model weight (kg/month) and height (cm/month) trajectories with knots at 3, 12, and 84 months. Analyses were conducted based on chronological age. RESULTS: There were 4423 children included with a mean of 11 weight and height measures per child. The mean age at the last visit was 5.9 years (Standard Deviation: 3.1). Generally, the more preterm, the lower the mean value of weight and height until early adolescence. Differences in mean weight and height for very/moderate preterm and late preterm compared to full term were evident until 12 months of age. Weight trajectories were similar between children born late preterm and full term with small differences from 84-168 months (mean difference (MD) -0.04 kg/month, 95% CI -0.06, -0.03). Children born late preterm had faster height gain from 0-3 months (MD 0.70 cm/month, 95% CI 0.42, 0.97) and 3-12 months (MD 0.17 cm/month, 95% CI 0.11, 0.22). CONCLUSIONS: Compared to full term, children born late preterm had lower average weight and height from birth to 14 years, had a slightly slower rate of weight gain after 84 months and a faster rate of height gain from 0-12 months. Follow-up is needed to determine if growth differences are associated with long-term disease risk.

Validation of Parent-reported Gestational Age Categories for Children Less Than 6 Years of Age.

BACKGROUND: Preterm birth is an important outcome or exposure in epidemiologic research. When administrative data on measured gestational age is not available, parent-reported gestational age can be obtained from questionnaires, which is subject to potential bias. To our knowledge, few studies have assessed the validity of parent-reported gestational age categories, including commonly defined categories of preterm birth. METHODS: We used linked data from primarily healthy children <6 years of age in TARGet Kids! in Toronto, Canada, and ICES administrative healthcare data from April 2011 to March 2020. We assessed the criterion validity of questionnaire-based parent-reported gestational age by calculating sensitivity and specificity for term (≥37 weeks), late preterm (34-36 weeks), and moderately preterm (32-33 weeks) gestational age categories, using administrative healthcare records of gestational age as the criterion standard. We conducted subgroup analyses for various parent and socioeconomic factors that may influence recall. RESULTS: Of the 4684 participants, 97.3% correctly classified the gestational age category according to administrative healthcare data. Parent-reported gestational age sensitivity ranged from 83.7% to 98.5% and specificity ranged from 88.3% to 99.8%, depending on category. For each subgroup characteristic, sensitivity and specificity were all ≥70%. Lower educational attainment, lower family income, father reporting, ≥1 year since birth, ≥2 children, lower parent age, and reported gestational diabetes and/or hypertension were associated with slightly lower sensitivity and/or specificity. CONCLUSIONS: In this linked cohort, parent-reported gestational age categories had high accuracy. Criterion validity varied minimally among some parent and socioeconomic factors. Our findings can inform future quantitative bias analyses.

A Feeding Adequacy Scale for Children With Bronchiolitis: Prospective Multicenter Study.

OBJECTIVES: To determine the measurement properties of the Feeding Adequacy Scale (FAS) in young children hospitalized with bronchiolitis. METHODS: Multicenter cohort study of infants hospitalized with bronchiolitis at children's and community hospitals in Ontario, Canada. Caregivers and nurses completed the FAS, a 10-cm visual analog scale anchored by "not feeding at all" (score 0) and "feeding as when healthy" (score 10). The main outcome measures were feasibility, reliability, validity, and responsiveness of the FAS. RESULTS: A total of 228 children were included with an average (SD) age of 6.3 (5.4) months. Completing the FAS was feasible for caregivers and nurses, with no floor or ceiling effects. Test-retest reliability was moderate for caregivers (intraclass correlation coefficient [ICC] 2,1 0.73; 95% confidence interval [CI] 0.63-0.80) and good for nurses (ICC 2,1 0.75; 95% CI 0.62-0.83). Interrater reliability between 1 caregiver and 1 nurse was moderate (ICC 1,1 0.55; 95% CI 0.45-0.64). For construct validity, the FAS was negatively associated with length of hospital stay and positively associated with both caregiver and nurse readiness for discharge scores (P values <.0001). The FAS demonstrated clinical improvement from the first FAS score at admission to the last FAS score at discharge, with significant differences between scores for both caregivers and nurses (P values for paired t test <.0001). CONCLUSIONS: These results provide evidence of the feasibility, reliability, validity, and responsiveness of caregiver-completed and nurse-completed FAS as a measure of feeding adequacy in children hospitalized with bronchiolitis.

Identifying strategies that support equitable person-centred osteoarthritis care for diverse women: content analysis of guidelines.

INTRODUCTION: Women are disproportionately impacted by osteoarthritis (OA) but less likely than men to access early diagnosis and management, or experience OA care tailored through person-centred approaches to their needs and preferences, particularly racialized women. One way to support clinicians in optimizing OA care is through clinical guidelines. We aimed to examine the content of OA guidelines for guidance on providing equitable, person-centred care to disadvantaged groups including women. METHODS: We searched indexed databases and websites for English-language OA-relevant guidelines published in 2000 or later by non-profit organizations. We used manifest content analysis to extract data, and summary statistics and text to describe guideline characteristics, person-centred care (PCC) using a six-domain PCC framework, OA prevalence or barriers by intersectional factors, and strategies to improve equitable access to OA care. RESULTS: We included 36 OA guidelines published from 2003 to 2021 in 8 regions or countries. Few (39%) development panels included patients. While most (81%) guidelines included at least one PCC domain, guidance was often brief or vague, few addressed exchange information, respond to emotions and manage uncertainty, and none referred to fostering a healing relationship. Few (39%) guidelines acknowledged or described greater prevalence of OA among particular groups; only 3 (8%) noted that socioeconomic status was a barrier to OA care, and only 2 (6%) offered guidance to clinicians on how to improve equitable access to OA care: assess acceptability, availability, accessibility, and affordability of self-management interventions; and employ risk assessment tools to identify patients without means to cope well at home after surgery. CONCLUSIONS: This study revealed that OA guidelines do not support clinicians in caring for diverse persons with OA who face disadvantages due to intersectional factors that influence access to and quality of care. Developers could strengthen OA guidelines by incorporating guidance for PCC and for equity that could be drawn from existing frameworks and tools, and by including diverse persons with OA on guideline development panels. Future research is needed to identify multi-level (patient, clinician, system) strategies that could be implemented via guidelines or in other ways to improve equitable, person-centred OA care. PATIENT OR PUBLIC CONTRIBUTION: This study was informed by a team of researchers, collaborators, and thirteen diverse women with lived experience, who contributed to planning, and data collection, analysis and interpretation by reviewing study materials and providing verbal (during meetings) and written (via email) feedback.

Examining the Double Burden of Underweight, Overweight/Obesity and Iron Deficiency among Young Children in a Canadian Primary Care Setting.

There is little evidence on the prevalence of the double burden and association between body mass index (BMI) and iron deficiency among young children living in high-income countries. We conducted a cross-sectional study of healthy children, 12-29 months of age, recruited during health supervision visits in Toronto, Canada, and concurrently measured BMI and serum ferritin. The prevalence of a double burden of underweight (zBMI < -2) and iron deficiency or overweight/obesity (zBMI > 2) and iron deficiency was calculated. Regression models examined BMI and serum ferritin as continuous and categorical variables, adjusted for covariates. We found the following in terms of prevalence among 1953 children (mean age 18.3 months): underweight 2.6%, overweight/obesity 4.9%, iron deficiency 13.8%, iron-deficiency anemia 5.4%, underweight and iron deficiency 0.4%, overweight/obesity and iron deficiency 1.0%. The change in median serum ferritin for each unit of zBMI was -1.31 µg/L (95% CI -1.93, -0.68, p < 0.001). Compared with normal weight, we found no association between underweight and iron deficiency; meanwhile, overweight/obesity was associated with a higher odds of iron deficiency (OR 2.15, 95% CI 1.22, 3.78, p = 0.008). A double burden of overweight/obesity and iron deficiency occurs in about 1.0% of young children in this high-income setting. For risk stratification and targeted screening in young children, overweight/obesity should be added to the list of important risk factors.