Nutritional Risk in Early Childhood and School Readiness.

BACKGROUND: Nutrition in early childhood is important for healthy growth and development. Achieving school readiness is considered one of the most important developmental milestones for young children. OBJECTIVES: The purpose of this study is to determine if nutritional risk in early childhood is associated with school readiness in kindergarten. METHODS: A prospective cohort study was conducted through The Applied Research Group for Kids (TARGet Kids!) primary care research network in Toronto, Canada, 2015-2020. Nutritional risk was measured (18 mo to 5 y) using validated parent-completed questionnaires called Nutrition Screening for Toddlers and Preschoolers (NutriSTEP). High nutritional risk was categorized as scores ≥21. School readiness was measured using the validated teacher-completed Early Developmental Instrument (EDI), which measures 5 developmental domains in kindergarten (2 y of schooling, ages 4-6 y, before they enter grade 1). Vulnerability indicates scores lower than a population-based cutoff at the 10th percentile on at least 1 domain. Multiple logistic and linear regression models were conducted adjusting for relevant confounders. RESULTS: The study included 896 children: 53% were male, 9% had high nutritional risk, and 17% were vulnerable on the EDI. A 1-SD increase in NutriSTEP total score was associated with 1.54 times increased odds of being vulnerable on the EDI among children in year 2 of kindergarten (P = 0.001). High nutritional risk cutoff was associated with 4.28 times increased odds of being vulnerable on the EDI among children in year 2 of kindergarten (P < 0.001). NutriSTEP total score and high nutritional risk were associated with lower scores on all 5 EDI domains, with the strongest association observed for the domains of language and cognitive development and communication skills and general knowledge. CONCLUSIONS: Higher nutritional risk in early childhood is associated with lower school readiness in year 2 of kindergarten. Nutritional interventions early in life may offer opportunities to enhance school readiness. This trial was registered www.clinicaltrials.gov as NCT01869530.

Nutritional risk in early childhood and parent-reported school concerns.

OBJECTIVE: To determine if nutritional risk in early childhood is associated with parent-reported school concerns. DESIGN: A prospective cohort study conducted through the TARGet Kids! primary care research network (2011-2018). Nutritional risk was measured between 18 months and 5 years of age using validated parent-completed NutriSTEP® questionnaires with eating behaviour and dietary intake subscores (0 = lowest and 68 = highest total nutritional risk score). Parent-reported school concerns were measured at school age (4-10 years of age) and included: speech and language; learning; attention; behaviour; social relationships; physical coordination; fine motor coordination and self-help skills and independence. The primary outcome was any parent-reported school concerns, and individual school concerns were used as secondary outcomes. Multiple logistic regression models were conducted adjusting for clinically relevant confounders to assess the relationship between nutritional risk and school concerns. SETTING: Toronto, Canada. PARTICIPANTS: Children aged 18 months to 10 years. RESULTS: The study included 3655 children, 52 % were male, mean NutriSTEP® score was 14·4 (sd 6·4). Each 1 sd increase in NutriSTEP® total score was associated with a 1·18 times increased odds of school concerns (adj OR: 1·18, 95 % CI 1·07, 1·28, P = 0·0004), and high nutritional risk was associated with a 1·42 times increased odds of school concerns (adj OR: 1·42, 95 % CI 1·13, 1·78, P = 0·002). CONCLUSIONS: Nutritional risk in early childhood was associated with school concerns. Nutritional interventions in early childhood may reveal opportunities to enhance school outcomes.

No association between metoclopramide treatment in ED and reduced risk of post-concussion headache.

OBJECTIVE: There is a lack of definitive pediatric literature on effective pharmacotherapy for persistent post-concussion headache symptoms. This study assessed whether acute metoclopramide treatment in the Emergency Department (ED) was associated with a reduction in persistent headache in children at 1- and 4-weeks post-concussion. METHODS: Children aged 8-17years with acute concussion presenting to 9-Canadian Pediatric EDs were enrolled in a prospective cohort study, from August 2013-June 2015. Primary and secondary outcomes were persistent headache at 1- and 4-week post-injury respectively. Headache persistence was based on the one and four-week headache scores minus recalled pre-injury score using the Post-Concussion Symptom Inventory. The association between metoclopramide and headache persistence at 1- and 4-weeks were examined using unadjusted and adjusted regression and 1:4 propensity score matching model. RESULTS: Baseline assessments were completed in 2095 participants; 65 (3.1%) received metoclopramide within 48-hours of injury. At 1- and 4-weeks, 54% (963/1808) and 26% (456/1780) of participants had persistent headache relative to baseline respectively. In unadjusted analysis, no association between metoclopramide and headache persistence at 1-week was found [treated vs. untreated: 1-week (53% vs. 53%; relative risk (RR)=1.0 (95%CI: 0.8, 1.3); 4-weeks (27.3% vs. 25.6%; RR=1.0 (95% CI: 0.9, 1.2)]. Metoclopramide was not associated with lower headache risk on propensity score matching [treated vs. untreated: 1-week, n=220 (52% vs. 59.4%; RR=0.8 (95%CI: 0.6, 1.2) and 4-weeks, n=225 (27.1% vs. 32.8%; RR=0.9 (95%CI: 0.8, 1.1)]. CONCLUSION: Metoclopramide administration was not associated with a reduction in headache persistence in children seeking ED care due to a concussion. Further research is necessary to determine which pharmacotherapies may be effective for acute and persistent post-concussive headache.

Residents' breastfeeding knowledge, comfort, practices, and perceptions: results of the Breastfeeding Resident Education Study (BRESt).

BACKGROUND: Physicians have a significant impact on new mothers' breastfeeding practices. However, physicians' breastfeeding knowledge is suboptimal. This knowledge deficit could be the result of limited breastfeeding education in residency. This study aimed to explore pediatric residents' breastfeeding knowledge, comfort level, clinical practices, and perceptions. It also investigated the level and type of education residents receive on breastfeeding and their preferences for improving it. METHODS: Descriptive, cross-sectional, self-reported online questionnaires were sent to all residents enrolled in a Canadian general pediatric residency program, as well as to their program directors. Resident questionnaires explored breastfeeding knowledge, comfort level, clinical practices, perceptions, educational experiences and educational preferences. Program director questionnaires collected data on current breastfeeding education in Canadian centers. For the resident survey, breastfeeding knowledge was calculated as the percent of correct responses. Demographic factors independently associated with overall knowledge score were identified by multiple linear regression. Descriptive statistics were used for the program director survey. RESULTS: Overall, 201 pediatric residents, and 14 program directors completed our surveys. Residents' mean overall breastfeeding knowledge score was 71% (95% CI: 69-79%). Only 4% (95% CI: 2-8%) of residents were very comfortable evaluating latch, teaching parents breastfeeding positioning, and addressing parents' questions regarding breastfeeding difficulties. Over a quarter had not observed a patient breastfeed. Nearly all agreed or strongly agreed that breastfeeding promotion is part of their role. Less than half reported receiving breastfeeding education during residency and almost all wanted more interactive breastfeeding education. According to pediatric program directors, most of the breastfeeding education residents receive is didactic. Less than a quarter of program directors felt that the amount of breastfeeding education provided was adequate. CONCLUSION: Pediatric residents in Canada recognize that they play an important role in supporting breastfeeding. Most residents lack the knowledge and training to manage breastfeeding difficulties but are motivated to learn more about breastfeeding. Pediatric program directors recognize the lack of breastfeeding education.

Concussion Symptom Prevalence, Severity and Trajectory: Implications for Nursing Practice.

PURPOSE: The purpose of this study was to describe the symptom severity and trajectory in concussed children who were followed during a one year period at a concussion clinic. DESIGN AND METHODS: A retrospective chart review was completed to describe the symptom trajectory up to three months during the recovery. RESULTS: One hundred and thirty-six patients were included (74 female, 62 male) with a median age of 15.4years (range 13-17). The most common mechanisms of injury included: falls (19.9%), hockey injuries (15.4%), soccer (14.0%) and football injuries (6.6%). Most concussion symptoms decreased in severity or improved over time. Four symptoms including fatigue/low energy, drowsiness, concentration difficulties and irritability had the highest symptoms scores at both 28 and 84days post-injury in patients with persistent symptoms. Emotionality and nervousness/anxiousness and nausea/vomiting scores were seen to increase over time in patients with persistent symptoms. IMPLICATIONS: Clinical use of standardized assessment tools can help caregivers track and monitor concussion symptoms over time. Appropriate management strategies need to be devised for symptoms that are prevalent or increasing over time.

Prevalence and risk factors for non-alcoholic fatty liver in children and youth with obesity.

BACKGROUND: Non- Alcoholic Fatty Liver (NAFL) is a spectrum of liver diseases (LD) that ranges from benign fatty infiltration of the liver to cirrhosis and hepatic failure. Hepatic ultrasound (US) and serum alanine aminotransferase (ALT) are often used as markers of NAFL. Our aim is to describe prevalence of NAFL and associated findings on ultrasound (US) and biochemical parameters in a population of children and adolescents with obesity at the Children's Hospital of Eastern Ontario. METHODS: Children with Obesity (BMI >95th percentile) ages 8-17 years presenting to the Endocrinology and Gastroenterology clinics, without underlying LD were prospectively recruited from 2009 to 2012. Fasting lipid profile, HOMA IR) and serum adiponectin levels were measured. NAFL was defined as ALT > 25 and >22 IU/mL (males and females respectively) and/or evidence of fatty infiltration by US. Logistic regression was performed to assess associations. RESULTS: 97 children with obesity included in the study (Male 43%). Mean age was 12.9 ± 3.2 years (84% were older than 10 y). Mean BMI-Z score was 3.8 ± 1.4. NAFL was identified in 85%(82/97) of participants. ALT was elevated in 61% of patients. Median triglyceride (TG) level was higher in children with NAFL(1.5 ± 0.9 vs. 1.1 ± 0.5 mmol/L, p = 0.01). Total cholesterol, HDL, LDL and Non HDL cholesterol were similar in both groups(p = 0.63, p = 0.98, p = 0.72 and p = 0.37 respectively). HOMA IR was ≥3.16 in 53% of children(55% in those with NAFL and 40% in those without NAFL). Median serum adiponectin was 11.2 µg/ml(IQR 7.3-18.3) in children with NAFL vs. 16.1 µg/ml(IQR 9.0-21.9) in those without NAFL(p = 0.23). Liver US was reported as normal in 30%, mild fatty infiltration in 38%, moderate in 20% and severe in 12%. TG were significantly higher(1.5 mmol/L vs. 1.0 mmol/L, p < 0.01) and HDL-C was lower(1.0 mmol/L vs. 1.1 mmol/L, p = 0.05) in children with moderate and severe NAFL by US. BMI-Z score, HOMA IR, serum adiponectin and HDL levels were not associated with NAFL, however TG were significantly associated(OR = 3.22 (95% CI: 1.01-10.25, p = 0.04)). CONCLUSION: NAFL is highly prevalent in obese children and youth. Elevated TG levels are associated with NAFL; these findings may serve as a noninvasive screening tool to help clinicians identify children with obesity needing liver biopsy and/or more aggressive therapeutic interventions.

Effect of High-Dose vs Standard-Dose Wintertime Vitamin D Supplementation on Viral Upper Respiratory Tract Infections in Young Healthy Children.

IMPORTANCE: Epidemiological studies support a link between low 25-hydroxyvitamin D levels and a higher risk of viral upper respiratory tract infections. However, whether winter supplementation of vitamin D reduces the risk among children is unknown. OBJECTIVE: To determine whether high-dose vs standard-dose vitamin D supplementation reduces the incidence of wintertime upper respiratory tract infections in young children. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial was conducted during the winter months between September 13, 2011, and June 30, 2015, among children aged 1 through 5 years enrolled in TARGet Kids!, a multisite primary care practice-based research network in Toronto, Ontario, Canada. INTERVENTIONS: Three hundred forty-nine participants were randomized to receive 2000 IU/d of vitamin D oral supplementation (high-dose group) vs 354 participants who were randomized to receive 400 IU/d (standard-dose group) for a minimum of 4 months between September and May. MAIN OUTCOME MEASURES: The primary outcome was the number of laboratory-confirmed viral upper respiratory tract infections based on parent-collected nasal swabs over the winter months. Secondary outcomes included the number of influenza infections, noninfluenza infections, parent-reported upper respiratory tract illnesses, time to first upper respiratory tract infection, and serum 25-hydroxyvitamin D levels at study termination. RESULTS: Among 703 participants who were randomized (mean age, 2.7 years, 57.7% boys), 699 (99.4%) completed the trial. The mean number of laboratory-confirmed upper respiratory tract infections per child was 1.05 (95% CI, 0.91-1.19) for the high-dose group and 1.03 (95% CI, 0.90-1.16) for the standard-dose group, for a between-group difference of 0.02 (95% CI, -0.17 to 0.21) per child. There was no statistically significant difference in number of laboratory-confirmed infections between groups (incidence rate ratio [RR], 0.97; 95% CI, 0.80-1.16). There was also no significant difference in the median time to the first laboratory-confirmed infection: 3.95 months (95% CI, 3.02-5.95 months) for the high-dose group vs 3.29 months (95% CI, 2.66-4.14 months) for the standard-dose group, or number of parent-reported upper respiratory tract illnesses between groups (625 for high-dose vs 600 for standard-dose groups, incidence RR, 1.01; 95% CI, 0.88-1.16). At study termination, serum 25-hydroxyvitamin D levels were 48.7 ng/mL (95% CI, 46.9-50.5 ng/mL) in the high-dose group and 36.8 ng/mL (95% CI, 35.4-38.2 ng/mL) in the standard-dose group. CONCLUSIONS AND RELEVANCE: Among healthy children aged 1 to 5 years, daily administration of 2000 IU compared with 400 IU of vitamin D supplementation did not reduce overall wintertime upper respiratory tract infections. These findings do not support the routine use of high-dose vitamin D supplementation in children for the prevention of viral upper respiratory tract infections. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01419262.

Progressive Hearing Loss in Early Childhood.

OBJECTIVES: Deterioration in hearing thresholds in children is of concern due to the effect on language development. Before universal newborn hearing screening (UNHS), accurate information on the progression of hearing loss was difficult to obtain due to limited information on hearing loss onset. The objective of this population-based study was to document the proportion of children who experienced progressive loss in a cohort followed through a UNHS program in one region of Canada. We explored risk factors for progression including risk indicators, audiologic, and clinical characteristics of children. We also investigated deterioration in hearing as a function of age. For this study, two working definitions of progressive hearing loss were adopted: (1) a change of ≥20 dB in the 3 frequencies (500, 1000, and 2000 Hz) pure-tone average, and (2) a decrease of ≥10 dB at two or more adjacent frequencies between 500 and 4000 Hz or a decrease in 15 dB at one octave frequency in the same frequency range. DESIGN: Population-based data were collected prospectively on a cohort of children identified from 2003 to 2013 after the implementation of UNHS. Clinical characteristics including risk indicators (as per Joint Committee on Infant Hearing), age at diagnosis, type and severity of hearing loss, and initial audiologic information were recorded when children were first identified with hearing loss. Serial audiometric results were extracted from the medical charts for this study. Differences between children with progressive and stable hearing loss were explored using χ tests. Association between risk indicators and progressive hearing loss was assessed through logistic regression. The cumulative amount of deterioration in hearing from 1 to 4 years of age was also examined. RESULTS: Our analysis of 330 children (251 exposed to screening) with detailed audiologic records showed that 158 (47.9%) children had some deterioration (at least ≥10 dB and) in hearing thresholds in at least one ear. The 158 children included 76 (48.1%) with ≥20 dB loss in pure-tone average in at least one ear and 82 (51.9%) with less deterioration in hearing levels (≥10 but <20 dB). In the children with progressive hearing loss, of 131 children initially diagnosed with bilateral loss, 75 (57.3%) experienced deterioration in 1 ear and 56 (112 ears; 42.7%) in both ears (total of 187 ears). Of 27 children with an initial diagnosis of unilateral loss, 25 experienced deterioration in the impaired ear and 5 in the normal-hearing ear, progressing to bilateral hearing loss. Within 4 years after diagnosis, the mean decrease in hearing for children with progressive loss was 25.9 dB (SD: 16.4) in the right ear and 28.3 dB (SD: 12.9) in the left ear. We explored the risk factors for hearing loss identified by Joint Committee on Infant Hearing where there were sufficient numbers in our sample. On multivariate analysis, there was no statistically significant relationship between most risk indicators examined (neonatal intensive care unit admission, family history, syndromes, and postnatal infections) and the likelihood of progressive loss. However, the presence of craniofacial anomalies was inversely associated with risk of progressive hearing loss (odds ratio = 0.27; 95% confidence interval: 0.10, 0.71; p = 0.01), that is, these children were more likely to have stable hearing. CONCLUSIONS: Given that almost half of the children in this cohort experienced deterioration in hearing, close postneonatal monitoring of hearing following early hearing loss identification is essential to ensure optimal amplification and therapy.

Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents.

Importance: Although concussion treatment guidelines advocate rest in the immediate postinjury period until symptoms resolve, no clear evidence has determined that avoiding physical activity expedites recovery. Objective: To investigate the association between participation in physical activity within 7 days postinjury and incidence of persistent postconcussive symptoms (PPCS). Design, Setting, and Participants: Prospective, multicenter cohort study (August 2013-June 2015) of 3063 children and adolescents aged 5.00-17.99 years with acute concussion from 9 Pediatric Emergency Research Canada network emergency departments (EDs). Exposures: Early physical activity participation within 7 days postinjury. Main Outcomes and Measures: Physical activity participation and postconcussive symptom severity were rated using standardized questionnaires in the ED and at days 7 and 28 postinjury. PPCS (≥3 new or worsening symptoms on the Post-Concussion Symptom Inventory) was assessed at 28 days postenrollment. Early physical activity and PPCS relationships were examined by unadjusted analysis, 1:1 propensity score matching, and inverse probability of treatment weighting (IPTW). Sensitivity analyses examined patients (≥3 symptoms) at day 7. Results: Among 2413 participants who completed the primary outcome and exposure, (mean [SD] age, 11.77 [3.35] years; 1205 [39.3%] females), PPCS at 28 days occurred in 733 (30.4%); 1677 (69.5%) participated in early physical activity including light aerobic exercise (n = 795 [32.9%]), sport-specific exercise (n = 214 [8.9%]), noncontact drills (n = 143 [5.9%]), full-contact practice (n = 106 [4.4%]), or full competition (n = 419 [17.4%]), whereas 736 (30.5%) had no physical activity. On unadjusted analysis, early physical activity participants had lower risk of PPCS than those with no physical activity (24.6% vs 43.5%; Absolute risk difference [ARD], 18.9% [95% CI,14.7%-23.0%]). Early physical activity was associated with lower PPCS risk on propensity score matching (n = 1108 [28.7% for early physical activity vs 40.1% for no physical activity]; ARD, 11.4% [95% CI, 5.8%-16.9%]) and on inverse probability of treatment weighting analysis (n = 2099; relative risk [RR], 0.74 [95% CI, 0.65-0.84]; ARD, 9.7% [95% CI, 5.7%-13.7%]). Among only patients symptomatic at day 7 (n = 803) compared with those who reported no physical activity (n = 584; PPCS, 52.9%), PPCS rates were lower for participants of light aerobic activity (n = 494 [46.4%]; ARD, 6.5% [95% CI, 5.7%-12.5%]), moderate activity (n = 176 [38.6%]; ARD, 14.3% [95% CI, 5.9%-22.2%]), and full-contact activity (n = 133 [36.1%]; ARD, 16.8% [95% CI, 7.5%-25.5%]). No significant group difference was observed on propensity-matched analysis of this subgroup (n = 776 [47.2% vs 51.5%]; ARD, 4.4% [95% CI, -2.6% to 11.3%]). Conclusions and Relevance: Among participants aged 5 to 18 years with acute concussion, physical activity within 7 days of acute injury compared with no physical activity was associated with reduced risk of PPCS at 28 days. A well-designed randomized clinical trial is needed to determine the benefits of early physical activity following concussion.

Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED.

IMPORTANCE: Approximately one-third of children experiencing acute concussion experience ongoing somatic, cognitive, and psychological or behavioral symptoms, referred to as persistent postconcussion symptoms (PPCS). However, validated and pragmatic tools enabling clinicians to identify patients at risk for PPCS do not exist. OBJECTIVE: To derive and validate a clinical risk score for PPCS among children presenting to the emergency department. DESIGN, SETTING, AND PARTICIPANTS: Prospective, multicenter cohort study (Predicting and Preventing Postconcussive Problems in Pediatrics [5P]) enrolled young patients (aged 5-<18 years) who presented within 48 hours of an acute head injury at 1 of 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network from August 2013 through September 2014 (derivation cohort) and from October 2014 through June 2015 (validation cohort). Participants completed follow-up 28 days after the injury. EXPOSURES: All eligible patients had concussions consistent with the Zurich consensus diagnostic criteria. MAIN OUTCOMES AND MEASURES: The primary outcome was PPCS risk score at 28 days, which was defined as 3 or more new or worsening symptoms using the patient-reported Postconcussion Symptom Inventory compared with recalled state of being prior to the injury. RESULTS: In total, 3063 patients (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 1205 [39.3%] girls) were enrolled (n = 2006 in the derivation cohort; n = 1057 in the validation cohort) and 2584 of whom (n = 1701 [85%] in the derivation cohort; n = 883 [84%] in the validation cohort) completed follow-up at 28 days after the injury. Persistent postconcussion symptoms were present in 801 patients (31.0%) (n = 510 [30.0%] in the derivation cohort and n = 291 [33.0%] in the validation cohort). The 12-point PPCS risk score model for the derivation cohort included the variables of female sex, age of 13 years or older, physician-diagnosed migraine history, prior concussion with symptoms lasting longer than 1 week, headache, sensitivity to noise, fatigue, answering questions slowly, and 4 or more errors on the Balance Error Scoring System tandem stance. The area under the curve was 0.71 (95% CI, 0.69-0.74) for the derivation cohort and 0.68 (95% CI, 0.65-0.72) for the validation cohort. CONCLUSIONS AND RELEVANCE: A clinical risk score developed among children presenting to the emergency department with concussion and head injury within the previous 48 hours had modest discrimination to stratify PPCS risk at 28 days. Before this score is adopted in clinical practice, further research is needed for external validation, assessment of accuracy in an office setting, and determination of clinical utility.

Empirical Derivation and Validation of a Clinical Case Definition for Neuropsychological Impairment in Children and Adolescents.

Neuropsychological assessment aims to identify individual performance profiles in multiple domains of cognitive functioning; however, substantial variation exists in how deficits are defined and what cutoffs are used, and there is no universally accepted definition of neuropsychological impairment. The aim of this study was to derive and validate a clinical case definition rule to identify neuropsychological impairment in children and adolescents. An existing normative pediatric sample was used to calculate base rates of abnormal functioning on eight measures covering six domains of neuropsychological functioning. The dataset was analyzed by varying the range of cutoff levels [1, 1.5, and 2 standard deviations (SDs) below the mean] and number of indicators of impairment. The derived rule was evaluated by bootstrap, internal and external clinical validation (orthopedic and traumatic brain injury). Our neuropsychological impairment (NPI) rule was defined as "two or more test scores that fall 1.5 SDs below the mean." The rule identifies 5.1% of the total sample as impaired in the assessment battery and consistently targets between 3 and 7% of the population as impaired even when age, domains, and number of tests are varied. The NPI rate increases in groups known to exhibit cognitive deficits. The NPI rule provides a psychometrically derived method for interpreting performance across multiple tests and may be used in children 6-18 years. The rule may be useful to clinicians and scientists who wish to establish whether specific individuals or clinical populations present within expected norms versus impaired function across a battery of neuropsychological tests.

Celecoxib pharmacogenetics and pediatric adenotonsillectomy: a double-blinded randomized controlled study.

BACKGROUND: Pediatric adenotonsillectomy (A&T) is associated with prolonged pain and functional limitation. Celecoxib is an effective analgesic in adult surgery patients; however, its analgesic efficacy on pain and functional recovery in pediatric A&T patients is unknown. METHODS: During 2009-2012, children (age 2-18 yr) scheduled for elective A&T were enrolled in a single-centre double-blind randomized controlled trial. Study participants received either oral placebo or celecoxib 6 mg·kg(-1) preoperatively, followed by 3 mg·kg(-1) twice daily for five doses. The primary outcome was the mean "worst 24-hr pain" scores during postoperative days (PODs) 0-2 on a 100-mm visual analogue scale (VAS). Secondary outcomes for PODs 0-7 included co-analgesic consumption, adverse events, and functional recovery. The impact of the CYP2C9*3 allele - associated with reduced celecoxib hepatic metabolism - on recovery was considered. RESULTS: Of the 282 children enrolled, 195 (celecoxib = 101, placebo = 94) were included in the primary outcome analysis. While on treatment, children receiving celecoxib experienced a modest reduction in the average pain experienced over PODs 0-2 (7 mm on a VAS; 95% confidence interval [CI]: 0.3 to 14; P = 0.04) and a "clinically significant" reduction (≥ 10 mm on a VAS; P ≤ 0.01) on PODs 0 and 1. During PODs 0-2, the mean acetaminophen consumption was lower in the celecoxib group vs the placebo group (78 mg·kg(-1); 95% CI: 68 to 89 vs 97 mg·kg(-1); 95% CI: 85 to 109, respectively; P = 0.03). No differences in adverse events, functional recovery, or satisfaction were observed by POD 7. The CYP2C9*3 allele was associated with less pain and improved functional recovery. CONCLUSIONS: A three-day course of oral celecoxib reduces early pain and co-analgesic consumption; however, an increase in dose, dose frequency, and duration of dose may be required for sustained pain relief in the pediatric setting. The CYP2C9*3 allele may influence recovery. This trial was registered at: ClinicalTrials.gov: NCT00849966.

Safety-engineered intravenous catheter utilization among Canadian pediatric anesthesiologists.

INTRODUCTION: Compared with other specialties, anesthesiologists are at increased risk of acquiring a blood-borne pathogen (BBP) through needle-stick injuries (NSIs). Safety-engineered intravenous catheters (SEICs) have been designed to reduce NSIs but have not been well received. Our objective was to determine SEIC usage by pediatric anesthesiologists, including availability, utilization, perceived utility, and sources of NSI before and after legislation mandating their use in Canada. METHODS: After Ethics Committee approval, we conducted two electronic surveys of Canadian pediatric anesthesiologists (CPAs) based in tertiary care settings. Survey responses from May through August 2012 and June through September 2006 were considered. In addition to SEIC use and perceived utility, respondents described factors influencing SEIC adoption and workplace NSIs. Standard metrics of survey validity and reliability were employed. RESULTS: Completed questionnaires were returned by 154 (69%) and 124 (53%) respondents in 2012 and 2006, respectively, representing 15 of 16 Canadian pediatric tertiary care centres. Reported SEIC availability increased in hospitals (82% vs 98%; difference in proportion 16%, 95% confidence interval [CI]: 9 to 24%; P < 0.001) and in operating rooms (62% vs 86%; difference in proportion 24%, 95% CI: 13 to 34%; P < 0.001) Respondents' report of "routine" personal use of SEICs increased from 43 of 76 (56%) to 112 of 132 (85%) (difference in proportion 29%, 95% CI: 16 to 41%; P < 0.001). Attitudes concerning perceived utility of SEICs remained unchanged and evenly split between respondents. "Awkward handling" remained the primary reason for non-use. In all, 71 (48%) and 60 (48%) respondents reported recent contaminated NSIs in 2012 and 2006, respectively. The majority were related to a needle on a disposable syringe. DISCUSSION: Despite only moderate perceived utility, SEIC uptake among CPAs is high. However, NSIs remain common. Several opportunities to reduce the risk for work-related BBP transmission among CPAs were evident.

Randomized controlled trial evaluating a virtual parenting intervention for young children at risk of obesity: study protocol for Parenting Addressing Early Years Intervention with Coaching Visits in Toronto (PARENT) trial.

BACKGROUND: The prevalence of overweight (15%) and obesity (6%) in children under 5 years of age in Canada are high, and young children with overweight and obesity are at increased risk of the development of chronic disease(s) in adulthood. Prior research has demonstrated very few published trials on effective obesity prevention interventions in young children at risk of obesity, within primary healthcare settings. The aim of this study is to determine if 18-48-month-old children at risk for obesity, who are randomized to receive the Parents Together program (i.e., intervention group), have reduced body mass index z-score (zBMI), compared to those not receiving the intervention, at a 12-month follow-up. Secondary clinical outcomes between the intervention and control groups will be compared at 12 months. METHODS: A pragmatic, parallel group, 1:1, superiority, randomized control trial (RCT) through the TARGetKids! Practice Based Research Network will be conducted. Young children (ages 18-48 months) who are at increased risk for childhood obesity will be invited to participate. Parents who are enrolled in the intervention group will participate in eight weekly group sessions and 4-5 coaching visits, facilitated by a trained public health nurse. Children and parents who are enrolled in the control group will receive the usual health care. The primary outcome will be compared between intervention arms using an analysis of covariance (ANCOVA). Feasibility and acceptability will be assessed by parent focus groups and interviews, and fidelity to the intervention will be measured using nurse-completed checklists. A cost-effectiveness analysis (CEA) will be conducted. DISCUSSION: This study will aim to reflect the social, cultural, and geographic diversity of children in primary care in Toronto, Ontario, represented by an innovative collaboration among applied child health researchers, community health researchers, and primary care providers (i.e., pediatricians and family physicians in three different models of primary care). Clinical and implementation outcomes will be used to inform future research to test this intervention in a larger number, and diverse practices across diverse geographic settings in Ontario. TRIAL REGISTRATION: ClinicalTrials.gov NCT03219697. Registered on June 27, 2017.

Early Life Antibiotic Prescription for Upper Respiratory Tract Infection Is Associated With Higher Antibiotic Use in Childhood.

BACKGROUND: Antibiotic prescription for uncomplicated upper respiratory tract infection (URTI) in children is not recommended but remains common. The primary objective was to evaluate the relationship between antibiotic prescription for URTI prior to age 2 and antibiotic prescription for URTI after age 2. It was hypothesized that antibiotic prescription for URTI in early childhood may increase the risk of antibiotic use for subsequent URTIs. The secondary objective was to investigate whether this relationship was different for acute otitis media (AOM), for which antibiotics may be indicated. METHODS: A prospective cohort study was conducted between December 2008 and March 2016 at 9 primary care practices in Toronto, Canada. Healthy children aged 0-5 years that met TARGet Kids! cohort eligibility criteria were included if they had at least one sick visit prior to age 2 and least one sick visit after age 2. Generalized Estimating Equation (GEE) models were used to evaluate this relationship while considering within-subject correlation. RESULTS: Of 2380 participants followed for a mean duration of 4.6 years, children who received an antibiotic prescription for URTI prior to age 2 had higher odds of receiving an antibiotic prescription for URTI in later childhood (adjusted odds ratio: 1.39; 95% confidence interval: 1.19 to 1.63; P < .001). This relationship did not appear to be different for AOM compared to non-AOM URTI. CONCLUSION: Antibiotic prescription for URTI before age 2 was associated with antibiotic prescription for URTI in later childhood. Reducing early life antibiotic prescription for URTI may be associated with reduction in antibiotic prescription for subsequent URTIs.

Delay in childhood vaccinations during the COVID-19 pandemic.

OBJECTIVES: In many jurisdictions, routine medical care was reduced in response to the COVID-19 pandemic. The objective of this study was to determine whether the frequency of on-time routine childhood vaccinations among children age 0-2 years was lower following the COVID-19 declaration of emergency in Ontario, Canada, on March 17, 2020, compared to prior to the pandemic. METHODS: We conducted a longitudinal cohort study of healthy children aged 0-2 years participating in the TARGet Kids! primary care research network in Toronto, Canada. A logistic mixed effects regression model was used to determine odds ratios (ORs) for delayed vaccination (> 30 days vs. ≤ 30 days from the recommended date) before and after the COVID-19 declaration of emergency, adjusted for confounding variables. A Cox proportional hazards model was used to explore the relationship between the declaration of emergency and time to vaccination. RESULTS: Among 1277 children, the proportion of on-time vaccinations was 81.8% prior to the COVID-19 declaration of emergency and 62.1% after (p < 0.001). The odds of delayed vaccination increased (odds ratio = 3.77, 95% CI: 2.86-4.96), and the hazard of administration of recommended vaccinations decreased after the declaration of emergency (hazard ratio = 0.75, 95% CI: 0.60-0.92). The median vaccination delay time was 5 days (95% CI: 4-5 days) prior to the declaration of emergency and 17 days (95% CI: 12-22 days) after. CONCLUSION: The frequency of on-time routine childhood vaccinations was lower during the first wave of the COVID-19 pandemic. Sustained delays in routine vaccinations may lead to an increase in rates of vaccine-preventable diseases.

RéSUMé: OBJECTIFS: Dans plusieurs juridictions, les soins médicaux systématiques étaient réduits à cause de la pandémie de COVID-19. L'objectif de cette étude était de déterminer si la fréquence de donner les vaccinations systématiques aux enfants de l'âge de 0 à 2 ans était réduite en conséquence de la déclaration d'urgence de COVID-19 en Ontario, Canada dès le 17 mars 2020, comparer avec la fréquence avant la pandémie. MéTHODES: Nous avons mené une étude de cohorte longitudinale des enfants en bonne santé âgés de 0 à 2 ans qui participent dans le réseau de recherche en soins primaires TARGet Kids! à Toronto, Canada. Un modèle de régression logistique à effets mixtes était utilisé pour déterminer le rapport de cotes (RC) pour les vaccinations retardées (> 30 jours c. ≤ 30 jours de la date recommandée) et était équilibré pour les variables confondantes. Le modèle à risques proportionnels de Cox était utilisé pour examiner le lien entre la déclaration d'urgence et le temps jusqu'à la vaccination. RéSULTATS: Parmi 1 277 enfants, la proportion de vaccination à l'heure était 81,8 % avant la déclaration d'urgence de COVID-19 et 62,1 % après (p < 0,001). La possibilité de vaccination retardée était augmentée (RC = 3,77; IC95% : 2,86­4,96), et le taux d'administration recommandé pour les vaccinations était réduit après la déclaration d'urgence (ratio de hasard = 0,75; IC95% : 0,60­0,92). Le médian temps de retard pour les vaccinations était 5 jours (IC95% : 4­5 jours) avant la déclaration d'urgence et 17 jours (IC95% : 12­22 jours) après. CONCLUSION: La fréquence de vaccinations systématiques aux enfants à l'heure était inférieure pendant la première vague de la pandémie COVID-19. Des retards soutenus pour recevoir les vaccinations systématiques peuvent entrainer une augmentation des taux de maladies évitables par la vaccination.

How safe are paediatric emergency departments? A national prospective cohort study.

BACKGROUND: Despite the high number of children treated in emergency departments, patient safety risks in this setting are not well quantified. Our objective was to estimate the risk and type of adverse events, as well as their preventability and severity, for children treated in a paediatric emergency department. METHODS: Our prospective, multicentre cohort study enrolled children presenting for care during one of 168 8-hour study shifts across nine paediatric emergency departments. Our primary outcome was an adverse event within 21 days of enrolment which was related to care provided at the enrolment visit. We identified 'flagged outcomes' (such as hospital visits, worsening symptoms) through structured telephone interviews with patients and families over the 21 days following enrolment. We screened admitted patients' health records with a validated trigger tool. For patients with flags or triggers, three reviewers independently determined whether an adverse event occurred. RESULTS: We enrolled 6376 children; 6015 (94%) had follow-up data. Enrolled children had a median age of 4.3 years (IQR 1.6-9.8 years). One hundred and seventy-nine children (3.0%, 95% CI 2.6% to 3.5%) had at least one adverse event. There were 187 adverse events in total; 143 (76.5%, 95% CI 68.9% to 82.7%) were deemed preventable. Management (n=98, 52.4%) and diagnostic issues (n=36, 19.3%) were the most common types of adverse events. Seventy-nine (42.2%) events resulted in a return emergency department visit; 24 (12.8%) resulted in hospital admission; and 3 (1.6%) resulted in transfer to a critical care unit. CONCLUSION: In this large-scale study, 1 in 33 children treated in a paediatric emergency department experienced an adverse event related to the care they received there. The majority of events were preventable; most were related to management and diagnostic issues. Specific patient populations were at higher risk of adverse events. We identify opportunities for improvement in care.

Adverse events in the paediatric emergency department: a prospective cohort study.

BACKGROUND: Understanding adverse events among children treated in the emergency department (ED) offers an opportunity to improve patient safety by providing evidence of where to focus efforts in a resource-restricted environment. OBJECTIVE: To estimate the risk of adverse events, their type, preventability and severity, for children seen in a paediatric ED. METHODS: This prospective cohort study examined outcomes of patients presenting to a paediatric ED over a 1-year period. The primary outcome was the proportion of patients with an adverse event (harm to patient related to healthcare received) related to ED care within 3 weeks of their visit. We conducted structured telephone interviews with all patients and families over a 3-week period following their visit to identify flagged outcomes (such as repeat ED visits, worsening symptoms) and screened admitted patients' health records with a validated trigger tool. For patients with flagged outcomes or triggers, three ED physicians independently determined whether an adverse event occurred. RESULTS: Of 1567 eligible patients, 1367 (87.2%) were enrolled and 1319 (96.5%) reached in follow-up. Median patient age was 4.34 years (IQR 1.5 to 10.57 years) and most (n=1281; 93.7%) were discharged. Among those with follow-up, 33 (2.5%, 95% CI 1.8% to 3.5%) suffered an adverse event related to ED care. None experienced more than one event. Twenty-nine adverse events (87.9%, 95% CI 72.7% to 95.2%) were deemed preventable. The most common types of adverse events (not mutually exclusive) were management issues (51.5%), diagnostic issues (45.5%) and suboptimal follow-up (15.2%). CONCLUSION: One in 40 children suffered adverse events related to ED care. A high proportion of events were preventable. Management and diagnostic issues warrant further study.

Public health preventive measures and child health behaviours during COVID-19: a cohort study.

OBJECTIVE: The primary objective was to determine the association between public health preventive measures and children's outdoor time, sleep duration, and screen time during COVID-19. METHODS: A cohort study using repeated measures of exposures and outcomes was conducted in healthy children (0 to 10 years) through The Applied Research Group for Kids (TARGet Kids!) COVID-19 Study of Children and Families in Toronto, Canada, between April 14 and July 15, 2020. Parents were asked to complete questionnaires about adherence to public health measures and children's health behaviours. The primary exposure was the average number of days that children practiced public health preventive measures per week. The three outcomes were children's outdoor time, total screen time, and sleep duration during COVID-19. Linear mixed-effects models were fitted using repeated measures of primary exposure and outcomes. RESULTS: This study included 554 observations from 265 children. The mean age of participants was 5.5 years, 47.5% were female and 71.6% had mothers of European ethnicity. Public health preventive measures were associated with shorter outdoor time (-17.2; 95% CI -22.07, -12.40; p < 0.001) and longer total screen time (11.3; 95% CI 3.88, 18.79; p = 0.003) during COVID-19. The association with outdoor time was stronger in younger children (<5 years), and the associations with total screen time were stronger in females and in older children (≥5 years). CONCLUSION: Public health preventive measures during COVID-19 were associated with a negative impact on the health behaviours of Canadian children living in a large metropolitan area.

RéSUMé: OBJECTIF: L'objectif principal était de déterminer la relation entre les mesures préventives de la santé publique et le temps passé en plein air, la durée du sommeil ainsi que le temps passé devant l'écran par les enfants pendant COVID-19. MéTHODES: Une étude de cohorte utilisant des mesures répétées des expositions et des effets a été menée chez des enfants en bonne santé (0 à 10 ans) par l'entremise de l'Étude COVID-19 sur les Enfants et Familles du Groupe de Recherche Appliquée pour les Enfants (TARGet Kids!) à Toronto, au Canada, entre le 14 avril et le 15 juillet 2020. Les parents ont été invités à remplir des questionnaires sur adhésion aux mesures préventives de la santé publique et les comportements de santé des enfants. La principale exposition était le nombre moyen de jours par semaine durant lesquels les enfants pratiquaient des mesures préventives de la santé publique. Les trois effets étaient le temps passé en plein air par les enfants, le temps total passé devant l'écran et la durée du sommeil pendant le COVID-19. Des modèles linéaires à effets mixtes ont été ajustés en utilisant des mesures répétées d'exposition primaire et des effets. RéSULTATS: Cette étude comprend 554 observations sur 265 enfants. L'âge moyen des participants était de 5,5 ans, 47,5 % étaient des femmes et 71,6 % avaient des mères d'origine européenne. Les mesures préventives de la santé publique ont été associées à un temps passé en plein air plus court (-17,2 ; IC 95% -22,07, -12,40; p < 0,001) et à un temps total devant l'écran plus long (11,3 ; IC 95% 3,88, 18,79; p = 0,003) pendant la COVID-19. La relation avec le temps passé en plein air était plus importante chez les jeunes enfants (<5 ans), et les relations avec le temps total passé devant l'écran étaient plus importantes chez les enfants de sexe féminin et les enfants plus âgés (≥5 ans). CONCLUSION: Les mesures préventives de la santé publique prises lors de COVID-19 ont été associées à un impact négatif sur les comportements de santé des enfants canadiens vivant dans une grande région métropolitaine.