Cohort profile update: The Canadian Maternal-Infant Research on Environmental Chemicals Child Development study (MIREC-CD PLUS).

BACKGROUND: The pan-Canadian Maternal-Infant Research on Environmental Chemicals (MIREC) study was established to determine whether maternal environmental chemical exposures were associated with adverse pregnancy outcomes in 2001 pregnant women. OBJECTIVES: The MIREC-Child Development (CD PLUS) study followed this cohort with the goal of assessing the potential effects of prenatal exposures on anthropometry and neurodevelopment in early childhood. POPULATION: MIREC families with children between the ages of 15 months and 5 years who had agreed to be contacted for future research (n = 1459) were invited to participate in MIREC-CD PLUS which combines data collected from an online Maternal Self-Administered Questionnaire with biomonitoring and neurodevelopment data collected from two in-person visits. PRELIMINARY RESULTS: Between April 2013 and March 2015, 803 children participated in the Biomonitoring visit where we collected anthropometric measures, blood, and urine from the children. The Behavioural Assessment System for Children-2, Behaviour Rating Inventory of Executive Function, MacArthur-Bates Communicative Development Inventories and the Communication subscale of the Adaptive Behaviour Scale from the Bayley Scales of Infant and Toddler Development-III are available on close to 900 children. There were 610 singleton children who completed in-person visits for neurodevelopment assessments including the Social Responsiveness Scale, Wechsler Preschool Primary Scale of Intelligence-III and NEuroPSYchological assessments (NEPSY). Currently, we are following the cohort into early adolescence to measure the impact of early life exposures on endocrine and metabolic function (MIREC-ENDO). CONCLUSIONS: Data collection for the MIREC-CD PLUS study is complete and analysis of the data continues. We are now extending the follow-up of the cohort into adolescence to measure the impact of early life exposures on endocrine and metabolic function (MIREC-ENDO). MIREC-CD PLUS is limited by loss to follow-up and the fact that mothers are predominately of higher socioeconomic status and 'White' ethnicity, which limits our generalizability. However, the depth of biomonitoring and clinical measures in MIREC provides a platform to examine associations of prenatal, infancy and childhood exposures with child growth and development.

Supporting and Incentivizing Peer Leaders for an Internet-Based Private Peer Community for Youths With Type 1 Diabetes: Social Network and Directed Content Analysis.

BACKGROUND: Youths with type 1 diabetes (T1D) frequently experience stigma. Internet-based peer communities can mitigate this through social support but require leaders to catalyze exchange. Whether nurturing potential leaders translates into a central role has not been well studied. Another issue understudied in such communities is lurking, the viewing of exchanges without commenting or posting. OBJECTIVE: We aimed to assess the centrality of the peer leaders we selected, trained, and incentivized within the Canadian Virtual Peer Network (VPN)-T1D. This is a private Facebook (Meta Platforms, Inc) group that we created for persons aged 14 to 24 years with T1D. We specifically sought to (1) compare a quantitative estimate of network centrality between peer leaders and regular members, (2) assess the proportions of network exchanges that were social support oriented, and (3) assess proportions of high engagement (posts, comments, reactions, and votes) and low engagement (lurking) exchanges. METHODS: We recruited peer leaders and members with T1D from prior study cohorts and clinics. We trained 10 leaders, provided them with a monthly stipend, and encouraged them to post on the private Facebook group we launched on June 21, 2017. We extracted all communications (posts, messages, reactions, polls, votes, and views) that occurred until March 20, 2020. We calculated each member's centrality (80% of higher engagement communications comprising posts, comments, and reactions plus 20% of members with whom they connected). We divided each member's centrality by the highest centrality to compute the relative centrality, and compared the mean values between leaders and members (linear regression). We calculated the proportions of communications that were posts, comments, reactions, and views without reaction. We performed content analysis with a social support framework (informational, emotional, esteem-related, network, and tangible support), applying a maximum of 3 codes per communication. RESULTS: VPN-T1D gained 212 regular members and 10 peer leaders over 33 months; of these 222 members, 26 (11.7%) exited. Peer leaders had 10-fold higher relative centrality than regular members (mean 0.53, SD 0.26 vs mean 0.04, SD 0.05; 0.49 difference; 95% CI 0.44-0.53). Overall, 91.4% (203/222) of the members connected at least once through posts, comments, or reactions. Among the 75,051 communications, there were 5109 (6.81%) posts, comments, and polls, 6233 (8.31%) reactions, and 63,709 (84.9%) views (lurking). Moreover, 54.9% (3430/6253) of codes applied were social support related, 66.4% (2277/3430) of which were informational (eg, insurance and travel preparation), and 20.4% (699/3430) of which were esteem related (eg, relieving blame). CONCLUSIONS: Designating, training, and incentivizing peer leaders may stimulate content exchange and creation. Social support was a key VPN-T1D deliverable. Although lurking accounted for a high proportion of the overall activity, even those demonstrating this type of passive participation likely derived benefits, given that the network exit rate was low. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/18714.

Albuminuria screening in children with type 1 diabetes prior to and during the COVID-19 pandemic.

BACKGROUND: Albuminuria is an important risk factor for adverse renal and cardiovascular outcomes in type 1 diabetes (T1D). We sought to describe: (1) adherence to albuminuria screening prior to and during the COVID-19 pandemic and (2) occurrence of abnormal urine albumin-creatinine ratio (ACR) tests in children with T1D. METHODS: This cohort study involved children aged 18 years or younger with T1D followed in the diabetes clinic at a pediatric tertiary center. Data was collected from 2016 to 2020. Adherence was defined by Diabetes Canada (DC) Guidelines for T1D in Children and Adolescents (2018). RESULTS: Of the 165 children who met DC criteria for screening; 88 (32%) were male and the median age at diagnosis was 5.8 years. Twenty-eight (17%) children had not completed a single ACR test, and 30 (18%) completed all eligible ACR tests. Test completion decreased from 66% in 2019 to 45% in 2020. Of the 345 ACR tests completed, 40 (11%) were abnormal (>2.5 mg/mmol) and 29 abnormal ACR tests (72%) were not repeated. CONCLUSION: Adherence to albuminuria screening in this pediatric diabetes clinic is suboptimal with deterioration during the COVID-19 pandemic. Patient/physician and program-level strategies to improve adherence will play an important role in quality improvement. IMPACT: Albuminuria screening is an important part of pediatric diabetes care. In our study, pediatric albuminuria screening adherence was suboptimal at 66% in 2019 and deteriorated during the pandemic to 45% in 2020. Program and patient-level adherence to clinical guidelines and barriers to accessing diabetes care during the pandemic merit further study.

Greater Arterial Stiffness in Children with or without Second-generation Antipsychotic Treatment for Mental Health Disorders: Rigidité Artérielle Plus Importante Chez Les Enfants Avec ou Sans Traitement Par Antipsychotiques de la Deuxième Génération Pour des Troubles de Santé Mentale.

OBJECTIVE: Second-generation antipsychotics (SGAs) are used for a variety of mental disorders and are associated with cardiometabolic side effects in children. The objective of this study was to assess the cardiovascular health of children with mental disorders that are SGA-treated or SGA-naive. METHODS: SGA-treated (n = 47) or SGA-naive (n = 37) children (aged 6 to 18 years) with mental disorders and control children (n = 83, no mental disorder) underwent assessment for cardiac function and morphology by echocardiography, aortic pulse wave velocity (PWV), and carotid intima-media thickness (cIMT). Body mass index (BMI) z-scores, waist circumference z-scores, systolic and diastolic blood pressure (BP) percentiles for height and sex, and fasting plasma glucose, insulin, triglycerides, and cholesterol were also assessed. Differences between SGA-treated, SGA-naive, and control children were assessed by linear and log-linear regression models. RESULTS: SGA-treated children had greater BMI z-scores and overweight/obesity (BMI ≥ 85th percentile for age and sex) and hypertension than SGA-naive and control children. The PWV geometric mean was 11.1% higher in SGA-treated (95%CI, 3.95 to 18.77) and 12.9% higher in SGA-naive children (95% CI, 5.60 to 20.59) compared to controls in models adjusted for age, sex, BMI, and systolic BP percentile. Left ventricular (LV) end-diastolic dimension/body surface area (BSA), LV end-systolic dimension/BSA, and LV ejection fraction were lower in SGA-treated and SGA-naive children compared to controls in models adjusted for sex and age. CONCLUSIONS: Children with mental disorders have greater arterial stiffness and altered cardiac structure/function than children with no mental health diagnosis. SGA treatment in children is not associated with alterations in cardiovascular structure/function.

Second-Generation Antipsychotic Use in Pediatric Emergency Medicine.

ABSTRACT: In recent years, the number of patients presenting to the emergency department with mental health complaints has been growing, alongside an increase in second-generation antipsychotic (SGAs) prescriptions for a variety of mental health conditions. Children treated with SGAs may have abnormalities, such as rapid weight gain and central adiposity, glucose intolerance, dyslipidemia, and hypertension; they may present to the pediatric emergency department with components of metabolic syndrome or type 2 diabetes, and a subsequent significant risk for cardiovascular complications later in life. Pediatric emergency department providers may serve as a safety net for patients to detect SGA-related metabolic complications, especially among vulnerable populations lacking access to primary care or psychiatric services.

Ambulatory blood pressure and carotid intima media thickness in children with type 1 diabetes.

BACKGROUND/OBJECTIVE: Blood pressure abnormalities may play an important role in macrovascular damage in type 1 diabetes. Little is known about blood pressure abnormalities and macrovascular damage in children with type 1 diabetes. METHODS: Children with type 1 diabetes (n = 57) for a short (3 months-2 years; n = 24) or long duration (≥5 years; n = 33) and a group of control children without diabetes (n = 29) completed 24-h ambulatory blood pressure monitoring (ABPM). Carotid intima media thickness (cIMT), a subclinical indicator of atherosclerosis, was assessed by carotid ultrasound. RESULTS: ABPM abnormalities were more prevalent (57% vs 24%, respectively), and daytime, nighttime and 24-h systolic, diastolic, and mean arterial blood pressure indices were higher in children with type 1 diabetes compared to control children. The odds estimate of an ABPM abnormality was 6.68 (95% confidence interval: 1.95, 22.9; P = .003) in children with type 1 diabetes compared to controls after adjusting for age, sex, and BMI standardized for age and sex (zBMI). An interaction between ABPM and zBMI on cIMT was observed. In children with type 1 diabetes and ABPM abnormalities, every 1 SD increase in zBMI was associated with a 0.030 mm increase in cIMT (95% confidence interval: 0.002, 0.041; P = .031). This was not observed in control children with ABPM abnormalities or in children with normal ABPM, regardless of type 1 diabetes status. CONCLUSIONS: Children with type 1 diabetes have a high prevalence of ABPM abnormalities independent of disease duration and this is related to early indicators of cardiovascular damage.

Risperidone But Not Quetiapine Treatment Is Associated With Increased Appetite But Not Satiety Hormones in Children During An Oral Glucose Tolerance Test: A Pilot Study.

BACKGROUND: Second-generation antipsychotics (SGAs) are commonly used to treat children with mental health conditions (MHCs) but are associated with adverse effects including obesity, hypertension, dyslipidemia, and type 2 diabetes. The mechanisms underlying these complications are unknown, but it has been suggested that SGAs increase appetite leading to weight gain. The present objective was to perform a pilot study to investigate appetite and satiety hormones in SGA-treated (risperidone or quetiapine) and SGA-naive children with similar mental health conditions. METHODS: Oral glucose tolerance tests (OGTTs) were conducted in SGA-naive (n = 18), risperidone-treated (n = 20), and quetiapine-treated (n = 16) children recruited from the British Columbia Children's Hospital Psychiatry Department. Over 5 time-points during the OGTT, appetite questionnaires using a visual analogue scale were administered, and blood was collected to measure ghrelin, peptide YY, glucose-dependent insulinotropic polypeptide, glucagon-like protein 1, leptin, and adiponectin. Mixed model analyses were conducted to examine between-group differences. RESULTS: The children were similar in age, psychiatric diagnosis, and global assessment of functioning scores. Body mass index z-scores were also similar between groups. Appetite was increased during the OGTT in the risperidone-treated compared with the SGA-naive group for 2 questions ("How strong is your desire to eat"; P = 0.003 and "How much food do you think you can eat"; P = 0.028). No differences in satiety hormones were observed between the 3 groups. CONCLUSIONS: Risperidone treatment in youth is associated with elevated appetite during an OGTT, with no differences in gut peptides or adipocytokines to explain risperidone's effect on appetite. Further research is needed to explore other mediators of weight gain and metabolic dysfunction in SGA-treated youth.

Adherence to a pediatric diabetic ketoacidosis protocol in children presenting to a tertiary care hospital.

OBJECTIVE: To review adherence to a provincial diabetic ketoacidosis (DKA) protocol and to assess factors associated with intravenous fluid administration and the length time on an insulin infusion. METHODS: A retrospective chart review was conducted of all DKA admissions to British Columbia Children's Hospital (BCCH) during September 2008 to December 2013. Data collection included diabetes history, estimation of dehydration, insulin and fluid infusion rates, and frequency of laboratory investigations. Markers of adherence included appropriate use of a fluid bolus, normal saline and insulin infusion time, fluid intake and outputs, and the frequency of blood work during the insulin infusion. A log-linear regression model was fitted to assess the factors associated with insulin infusion duration. RESULTS: Of 157 children (median [interquartile range] age: 10.6 years [5.0, 13.8]) hospitalized for DKA, 45% (n = 70) were male, 55% (n = 86) were transferred from other hospitals, and 26% (n = 40) were admitted to intensive care unit. Thirty-five percent of subjects estimated to have mild or moderate dehydration received fluid boluses. In the adjusted analysis, the average duration on DKA protocol was 39% (95% confidence interval [CI]: 12%, 67%) longer for children admitted with severe dehydration (compared to those with mild dehydration). CONCLUSIONS: Health care providers' adherence to the BCCH DKA protocol is poor. More severe dehydration at presentation is associated with longer duration of insulin infusion. Further knowledge translation initiatives focused on accurate estimation of volume depletion to ensure appropriate initial fluid resuscitation-as well as careful monitoring during DKA hospitalization-are important, especially in community centers.

Stigma and Its Association With Glycemic Control and Hypoglycemia in Adolescents and Young Adults With Type 1 Diabetes: Cross-Sectional Study.

BACKGROUND: Qualitative studies in type 1 diabetes indicate that visibility of diabetes supplies, self-care, and hypoglycemia symptoms are associated with stigma and suboptimal management. This may be particularly salient in youth who face concurrent challenges such as establishing autonomy and making vocational choices. OBJECTIVE: The aim of the study was to estimate stigma prevalence in youth (aged 14-24 years) with type 1 diabetes and its associations with glycemic control. METHODS: Participants, recruited largely through social media, were asked to complete a Web-based survey and to send via mail capillary blood samples for glycated hemoglobin (HbA1c) measurement. The primary definition of stigma required endorsement of one or more of 3 stigma-specific items of the Barriers to Diabetes Adherence questionnaire. These addressed avoidance of diabetes management with friends present, difficulty telling others about diabetes diagnosis, and embarrassment in performing diabetes care with others present. Poor glycemic control was defined as HbA1c>9% (ie, >75 mmol/mol; measured value when available, else self-report) and/or ≥1 severe hypoglycemic episode in the previous year (reported requiring assistance from someone else during the episode). Stigma prevalence was computed (95% CI), and associations with glycemic control were evaluated (multivariate logistic regression models). RESULTS: Among the 380 respondents, stigma prevalence was 65.5% (95% CI 60.7-70.3). Stigma was associated with a 2-fold higher odds of poor glycemic control overall (odds ratio [OR] 2.25, 95% CI 1.33-3.80; adjusted for age, sex, and type of treatment). There were specific associations with both HbA1c>9% (75 mmol/mol; OR 3.05, 95% CI 1.36-6.86) and severe hypoglycemia in the previous year (OR 1.86, 95% CI 1.05-3.31). CONCLUSIONS: There is a high prevalence of stigma in youth with type 1 diabetes that is associated with both elevated HbA1c levels and severe hypoglycemia. Targeted strategies to address stigma are needed. TRIAL REGISTRATION: ClinicalTrials.gov NCT02796248; http://clinicaltrials.gov/ct2/show/NCT02796248 (Archived by WebCite at http://www.webcitation.org/6yisxeV0B).

Second-generation antipsychotics in children: Risks and monitoring needs.

Question A 10-year-old male patient presented to my clinic with irritability associated with autism spectrum disorder, and previous therapeutic efforts had not been successful. Treatment with quetiapine has considerably reduced irritability and improved his quality of life; however, the patient's mother has stated that her child's clothes are no longer fitting because his waist size has increased substantially, and that he has gained 5 kg since treatment initiation 8 weeks ago. Should second-generation antipsychotic (SGA) treatment be stopped or continued, and how can these side effects be best mitigated in a family practice setting?Answer Use of SGAs in pediatric patients has increased in recent years, which has brought to light a number of worrisome metabolic side effects that occur in children. Owing to the efficacy of treatment, SGAs must often be continued despite side effects. Even if the drug has been prescribed elsewhere, family physicians should closely monitor these patients following the Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children guidelines. When starting an SGA, patients and their families should be educated on the importance of healthy eating and physical activity to preemptively mitigate potential side effects. Recent studies have also shown adjunctive metformin to have a potential role in reducing weight gain.

Does parental and adolescent participation in an e-health lifestyle modification intervention improves weight outcomes?

BACKGROUND: Few studies have evaluated the effect of adherence to a lifestyle intervention on adolescent health outcomes. The objective of this study was to determine whether adolescent and parental adherence to components of an e-health intervention resulted in change in adolescent body mass index (BMI) and waist circumference (WC) z-scores in a sample of overweight/obese adolescents. METHODS: In total, 159 overweight/obese adolescents and their parents participated in an 8-month e-health lifestyle intervention. Each week, adolescents and their parents were asked to login to their respective website and to monitor their dietary, physical activity, and sedentary behaviours. We examined participation (percentage of webpages viewed [adolescents]; number of weeks logged in [parents]) and self-monitoring (number of weeks behaviors were tracked) rates. Linear mixed models and multiple regressions were used to examine change in adolescent BMI and WC z-scores and predictors of adolescent participation and self-monitoring, respectively. RESULTS: Adolescents and parents completed 28% and 23%, respectively, of the online component of the intervention. Higher adolescent participation rate was associated with a decrease in the slope of BMI z-score but not with change in WC z-score. No association was found between self-monitoring rate and change in adolescent BMI or WC z-scores. Parent participation was not found to moderate the relationship between adolescent participation and weight outcomes. CONCLUSIONS: Developing strategies for engaging and promoting supportive interactions between adolescents and parents are needed in the e-health context. Findings demonstrate that improving adolescents' adherence to e-health lifestyle intervention can effectively alter the weight trajectory of overweight/obese adolescents.

Persistent Albuminuria in Children with Type 2 Diabetes: A Canadian Paediatric Surveillance Program Study.

OBJECTIVE: To determine the prevalence and the clinical features associated with persistent albuminuria in Canadian children aged <18 years with type 2 diabetes. STUDY DESIGN: This national prospective surveillance study involved a network of pediatricians and pediatric endocrinologists. Cases of persistent albuminuria in children with type 2 diabetes were reported during a 24-month period from 2010 to 2012. Persistent albuminuria was defined as an elevated albumin-to-creatinine ratio in a minimum of 2 out of 3 urine samples obtained at least 1 month apart over 3-6 months and confirmed with a first morning sample. Descriptive statistics were used to illustrate demographic and clinical features of the population. The prevalence of persistent albumuria was estimated using data from a previous national surveillence study of type 2 diabetes in children. RESULTS: Fifty cases were reported over the 24-month study period. The estimated prevalence of persistent albuminuria in children with type 2 diabetes in Canada was 5.1%. The median duration of diabetes at the time of diagnosis of albuminuria was 21 days (IQR, 0-241 days). Almost two-thirds (64%) were female, 80% were of Canadian First Nations heritage, and 76% were from Manitoba. Exposure to gestational or pregestational diabetes in utero occurred in 65%, and 48% had a family history of diabetes-related renal disease. Structural anomalies of the kidney were found in 37%. CONCLUSION: Persistent albuminuria occurs in youths with type 2 diabetes in the first year after diagnosis, demonstrates regional variation, and is associated with First Nations heritage and exposure to maternal diabetes during pregnancy.

Obesity and arterial stiffness in children: systematic review and meta-analysis.

OBJECTIVE: Childhood obesity is associated with risk factors for cardiovascular disease. Arterial stiffness is considered one of the earliest detectable measures of vascular damage. There is controversy in the literature regarding the effects of childhood obesity on arterial stiffness. The objective of this study is to systematically review the literature and to conduct a meta-analysis comparing measures of central arterial stiffness in children and adolescents with obesity to healthy body mass index controls. APPROACH AND RESULTS: Literature searches were conducted using databases (eg, MEDLINE, EMBASE) and citations cross-referenced. Studies assessing central pulse wave velocity or ß-stiffness index were included. A random effects meta-analysis of the standardized mean difference and 95% confidence intervals in arterial stiffness between children with obesity and control children was performed for each arterial stiffness measure. A total of 523 studies were identified. Fifteen case-control studies were included, with 2237 children/adolescents (1281 with obesity, 956 healthy body mass index controls) between 5 and 24 years of age. All studies measuring carotid and aortic ß-stiffness index and 10/12 studies measuring central pulse wave velocity reported greater arterial stiffness in children/adolescents with obesity compared with controls. A random effects meta-analysis was performed revealing a significant effect of obesity on pulse wave velocity (standardized mean difference=0.718; 95% confidence interval=0.291-1.415), carotid ß-stiffness index (0.862; 0.323-1.402), and aortic ß stiffness index (1.017; 0.419-1.615). CONCLUSION: These findings indicate that child/adolescent obesity is associated with greater arterial stiffness. However, further research is needed to address confounders, such as pubertal status, that may affect this relationship in children. In the future, these techniques may be useful in risk stratification and guiding clinical management of obese children to optimize cardiovascular outcomes.

Individual and household predictors of adolescents' adherence to a web-based intervention.

BACKGROUND: Adherence to e-health obesity interventions is a significant challenge. PURPOSE: We examined the individual and household predictors of adolescents' adherence to a Web-based lifestyle intervention. METHODS: One hundred sixty overweight/obese adolescents and one of their parents enrolled in the 8-month e-health intervention. Structural equation modeling was used to examine individual factors from the theory of planned behavior and self-determination theory and household factors (food/soda availability, parenting, environment) that predict adolescents' adherence to components of the intervention. RESULTS: We explained 10.8 to 36.9% of the total variance in adherence to components of the intervention. Intrinsic motivation and parenting practices and styles directly predicted adherence. Relatedness and autonomy support indirectly predicted adherence via intrinsic motivation. Finally, household income modulated these effects. CONCLUSION: Taking a self-regulatory perspective (i.e., accounting for intrinsic motivation) contributes to our understanding of intervention adherence, but the household environment may play a greater role in facilitating adolescent behavior change.

Adrenal Suppression in Children Treated With Oral Viscous Budesonide for Eosinophilic Esophagitis.

We sought to determine the prevalence of adrenal suppression (AS) in children with eosinophilic esophagitis treated with oral viscous budesonide (OVB). This was a retrospective review of a quality assurance initiative, whereby all children in our center treated with OVB for ≥3 months were referred over an 18-month time frame for endocrine assessment including 1 µg adrenocorticotropic hormone stimulation test. Fourteen of 19 children complied with the referral; of these 14 children, 6 (43%) had suboptimal stimulated cortisol (range 343-497 nmol/L, mean [±SD] 424.7 nmol/L [±52.4], normal ≥500 nmol/L). There was no significant association to treatment duration, dose, or concomitant use of inhaled/nasal corticosteroids. This study suggests that children treated with OVB may be at risk for AS.

Increased Risk of Obesity and Metabolic Dysregulation Following 12 Months of Second-Generation Antipsychotic Treatment in Children: A Prospective Cohort Study.

OBJECTIVE: To determine the risk of developing obesity and related metabolic complications in children following long-term treatment with risperidone or quetiapine. METHODS: This was a 1-year naturalistic longitudinal study conducted between February 2009 and March 2012. A total of 130 children aged 2 to 18 years without prior exposure to second-generation antipsychotics (SGAs) were enrolled at initiation of treatment with either risperidone or quetiapine. Metabolic parameters were measured at baseline and months 6 and 12. Data of 37 participants (20 treated with risperidone and 17 treated with quetiapine) who completed 12-month monitoring were used in the analysis. RESULTS: After 1 year of SGA treatment, mean weight increased significantly by 10.8 kg (95% CI 7.9 kg to 13.7 kg) for risperidone and 9.7 kg (95% CI 6.5 kg to 12.8 kg) for quetiapine. Body mass index z score also increased significantly in both groups (P < 0.001). There was a high incidence of children becoming overweight or obese (6/15 [40.0%] for risperidone-treated and 7/14 [50.0%] for quetiapine-treated). The mean levels of fasting glucose (for risperidone-treated) and ratio of total cholesterol to high-density lipoprotein cholesterol (for quetiapine-treated) increased significantly by 0.23 mmol/L (95% CI 0.03 mmol/L to 0.42 mmol/L) and 0.48 mmol/L (95% CI 0.15 mmol/L to 0.80 mmol/L), respectively. CONCLUSION: Children treated with risperidone or quetiapine are at a significant risk for developing obesity, elevated waist circumference, and dyslipidemia during 12 months of treatment. These data emphasize the importance of regular monitoring for early identification and treatment of metabolic side effects.

Effectiveness of an educational handbook in improving psychiatry resident knowledge of second-generation antipsychotics.

OBJECTIVE: The authors describe a pilot evaluation of an educational handbook designed to increase resident knowledge of second-generation antipsychotic (SGA) use in the pediatric population, with an emphasis on metabolic monitoring. METHODS: An educational handbook focusing on SGA use in children and adolescents was introduced to psychiatry residents undergoing a child psychiatry rotation. Baseline and post-intervention questionnaires were administered to determine whether SGA knowledge increased. RESULTS: Baseline and post-intervention questionnaires were completed by 32 residents. At baseline, most residents (92.9 %) had interacted with an adult patient requiring an SGA and had prescribed SGAs at least five times (70.9 %) in the previous month. Baseline SGA knowledge was limited such that only 5.4 % of participants scored greater than 80 %, and 28.6 % scored below 60 %. Mean total score improved significantly from pre-test (18.4 ± 4.23) to post-test (21.2 ± 3.28, p = 0.001). Stratified analysis suggested a significant improvement of scores (post-test versus pre-test, respectively) in females (21.8 ± 3.11 versus 18.0 ± 4.94, p = 0.003) and junior residents (21.3 ± 3.34 versus 18.1 ± 4.37, p = 0.001). While significant improvements were documented in questions related to Health Canada-approved and other off-label evidence-based indications, and the appropriate physical examination components and laboratory tests to perform at SGA initiation and follow-up, no improvements were documented regarding the distinguishing properties, side effects, and appropriate history-taking prior to SGA initiation. CONCLUSIONS: Implementation of an educational handbook can improve resident knowledge related to SGA use in children over the short-term. However, future research should be directed at the effectiveness of more interactive web-based formats in optimizing learning for male residents and ensuring more comprehensive knowledge uptake. While the introduction of an education handbook is the first step in addressing some of the barriers to metabolic monitoring, prospective longitudinal studies are required to determine whether such an intervention will ultimately improve prescriber adherence over the long-term.

Quetiapine treatment in youth is associated with decreased insulin secretion.

Second-generation antipsychotics (SGAs) are commonly prescribed to youth but are associated with metabolic effects including obesity and diabetes. The mechanisms underlying diabetes development are unclear. The purpose of this study was to compare glucose homeostasis, insulin sensitivity, insulin secretion, and overall ß-cell function in risperidone-treated, quetiapine-treated, and SGA-naive youth with mental illness. We conducted a cross-sectional study in which youth aged 9 to 18 years underwent a 2-hour oral glucose tolerance test. Indices for insulin sensitivity (Matsuda index), insulin secretion (insulinogenic index), and ß-cell function (insulin secretion-sensitivity index-2 [ISSI-2]) were calculated. A total of 18 SGA-naive, 20 risperidone-treated, and 16 quetiapine-treated youth participated. The 3 groups were similar in age, sex, ethnicity, body mass index standardized for age and sex, pubertal status, degree of psychiatric illness, psychiatric diagnoses, and other medications. The median treatment duration was 17 months (range, 3-91 months) for risperidone-treated youth and 10 months (range, 3-44 months) for quetiapine-treated youth. The quetiapine-treated group had lower insulinogenic index (P < 0.01) and lower ISSI-2 (P < 0.01) compared with that in the SGA-naive group. Only the body mass index standardized for age and sex was negatively associated with Matsuda index (ß = -0.540, P < 0.001) in all youth. Quetiapine treatment was negatively associated with insulinogenic index (ß = -0.426, P = 0.007) and ISSI-2 (ß = -0.433, P = 0.008). Quetiapine reduced the insulin expression in isolated mouse islets suggesting a direct ß-cell effect. Our results suggest that quetiapine treatment in youth is associated with impaired ß-cell function, specifically lower insulin secretion. Prospective longitudinal studies are required to understand the progression of ß-cell dysfunction after quetiapine initiation.

Initial screening of children treated with second-generation antipsychotics points to an association between physical activity and insulin resistance.

Second-generation antipsychotic (SGA) medications, used to treat youth for a wide-range of mental health conditions, are associated with excessive weight gain and other comorbidities, placing these individuals at high risk for cardiovascular disease. Little is known about the effect of physical activity (PA) on cardiovascular risk in these children. Anthropometrics, fasting blood sample and self-report PA were obtained in 386 children diagnosed with mental health conditions (6-18 y). PA was classified as below (<60 min/day) or meets (≥60 min/day) current recommended guidelines for daily PA in children. SGA-treated (n = 166) and SGA-naïve (n = 220) were compared in the analysis. The SGA-treated children had higher (p < .05) BMI z-score, waist-to-height ratio, fasting glucose, and LDL-cholesterol than SGA-naïve children. Waist circumference, waist-to-height ratio, HDL cholesterol, fasting insulin, and HOMA-IR were significantly different by PA status. After adjusting for SGA-treatment duration, sex, age, and ethnicity, higher PA was associated with lower insulin resistance (HOMA-IR) in SGA-treated (mean, 95% CI; below vs. meets: 2.10 [1.84, 2.37] vs. 1.59 [1.37, 1.81], p = .046) but not in SGA-naïve (1.70 [1.47, 1.94] vs. 1.55 [1.35, 1.75], p = .707) children. Upon initial screening, SGA-treated children that reported meeting the minimal recommendations for daily PA displayed lower measures of adiposity and improved insulin resistance.

Cardiovascular risk factors and health behaviours in elementary school-age Inuvialuit and Gwich'in children.

OBJECTIVES: To determine cardiovascular risk factors and health behaviours in Aboriginal children from the Beaufort-Delta region (Northwest Territories). METHODS: A total of 91 elementary school-age children underwent a cross-sectional assessment of body mass index, waist circumference, blood pressure and aerobic fitness. Healthy living knowledge and behaviours, including frequency of self-reported physical activity (PA) and dietary intake, were also evaluated. RESULTS: A total of 49.5% of children were obese/overweight and 31.9% had elevated blood pressure. The percentages having one, two or three cardiovascular risk factor(s) were 64.4%, 42.2% and 15.6%, respectively, with no significant difference between boys and girls. Overall, the students obtained higher mean scores in the areas of healthy PA, body image, self-esteem and nutritious beverage knowledge (89%, 85%, 79% and 71% of the maximum scores, respectively). The lowest scores were in nutritious food consumption and healthy PA frequency (46% and 56% of the maximum scores, respectively). On average, children consumed 2.7 L of sugar-sweetened beverages weekly and <2 servings of fruits or vegetables daily. Children spent approximately 2 h per day watching television, playing games or using a computer. CONCLUSION: There is an urgent need for community-based approaches to address the high rates of obesity and related cardiovascular risk factors among these Aboriginal children. Given the disconnect between healthy living knowledge and behaviour, it is important that future treatment programs address other barriers faced by Aboriginal populations living in rural and remote regions, including the high cost and limited access to high-quality nutritious foods and beverages, and limited access to indoor recreational programs over the long winter season.

OBJECTIFS: Déterminer les facteurs de risque cardiovasculaire et les comportements de santé des enfants autochtones de la région de Beaufort-Delta (Territoires du Nord-Ouest). MÉTHODOLOGIE: Les chercheurs ont effectué l'évaluation transversale de l'indice de masse corporelle, du tour de taille, de la tension artérielle et de la capacité aérobique de 91 enfants du primaire. Ils ont également évalué leurs connaissances et leurs comportements liés à un mode de vie sain, y compris la fréquence de l'activité physique (AP) et la consommation alimentaire autodéclarées. RÉSULTATS: Au total, 49,5 % des enfants étaient obèses ou faisaient de l'embonpoint, et 31,9 % avaient une tension artérielle élevée. De plus, 64,4 %, 42,2 % et 15,6 % d'entre eux avaient un, deux ou trois facteurs de risque cardiovasculaire, respectivement. Il n'y avait pas de différence significative entre les garçons et les filles. Dans l'ensemble, les élèves obtenaient des résultats moyens plus élevés en matière d'AP saine, d'image corporelle, d'estime de soi et de connaissances sur les boissons nutritives (89 %, 85 %, 79 % et 71 % des résultats maximaux, respectivement). Les résultats les plus faibles étaient liés à la consommation d'aliments nutritifs et à la fréquence d'AP (46 % et 56 % des résultats maximaux, respectivement). En moyenne, les enfants consommaient 2,7 litres de boissons sucrées par semaine et moins de deux portions de fruits ou de légumes par jour. Les enfants consacraient environ deux heures par jour à regarder la télévision, à jouer à des jeux ou à utiliser l'ordinateur. CONCLUSION: Il est urgent d'adopter des approches communautaires pour atténuer les taux élevés d'obésité et de facteurs de risque cardiovasculaire connexes chez ces enfants autochtones. Étant donné la dichotomie entre les connaissances sur un mode de vie sain et le comportement, les prochains programmes thérapeutiques devront absolument tenir compte des autres obstacles qu'affrontent les populations autochtones des régions rurales et éloignées, y compris l'accès limité à des aliments nutritifs et des boissons de qualité et leur coût élevé, de même que l'accès limité aux activités récréatives intérieures pendant la saison hivernale.