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OBJECTIVES: We aimed to examine the impact of a quality improvement (QI) collaborative on adherence to specific recommendations within the American Academy of Pediatrics' Clinical Practice Guideline (CPG) for well-appearing febrile infants aged 8 to 60 days. METHODS: Concurrent with CPG release in August 2021, we initiated a QI collaborative involving 103 general and children's hospitals across the United States and Canada. We developed a multifaceted intervention bundle to improve adherence to CPG recommendations for 4 primary measures and 4 secondary measures, while tracking 5 balancing measures. Primary measures focused on guideline recommendations where deimplementation strategies were indicated. We analyzed data using statistical process control (SPC) with baseline and project enrollment from November 2020 to October 2021 and the intervention from November 2021 to October 2022. RESULTS: Within the final analysis, there were 17 708 infants included. SPC demonstrated improvement across primary and secondary measures. Specifically, the primary measures of appropriately not obtaining cerebrospinal fluid in qualifying infants and appropriately not administering antibiotics had the highest adherence at the end of the collaborative (92.4% and 90.0% respectively). Secondary measures on parent engagement for emergency department discharge of infants 22 to 28 days and oral antibiotics for infants 29 to 60 days with positive urinalyses demonstrated the greatest changes with collaborative-wide improvements of 16.0% and 20.4% respectively. Balancing measures showed no change in missed invasive bacterial infections. CONCLUSIONS: A QI collaborative with a multifaceted intervention bundle was associated with improvements in adherence to several recommendations from the AAP CPG for febrile infants. [ABSTRACT FROM AUTHOR]

The article presents a clinical practice guideline (CPG) on pediatric neurogenic lower urinary tract dysfunction (NLUTD) developed by the Canadian Urological Association (CUA) and the Pediatric Urologists of Canada (PUC). It focuses on pediatric patients with neurological conditions causing urinary dysfunction. It further emphasizes the importance of diagnosis, conservative management, surgical interventions, and long-term follow-up.

BACKGROUND: For 60 y, the people of Asubpeeschoseewagong Anishinabek (Grassy Narrows First Nation) have endured the effects of massive mercury (Hg) contamination of their river system, central to their traditions, culture, livelihood, and diet. In the years following the Hg discharge into the English-Wabigoon River system by a chloralkali plant in the early 1970s, there was a dramatic increase in youth suicides. Several authors attributed this increase solely to social disruption caused by the disaster. OBJECTIVE: This research examined the possible contribution of Hg exposure across three generations on attempted suicides among today's children (5-11 y old) and youth (12-17 y old), using a matrilineal intergenerational paradigm. METHODS: Information from the 2016-2017 Grassy Narrows Community Health Assessment (GN-CHA) survey was merged with Hg biomonitoring data from government surveillance programs (1970-1997). Data from 162 children/youth (5-17 years of age), whose mothers (푛=80) had provided information on themselves, their parents, and children, were retained for analyses. Direct and indirect indicators of Hg exposure included a) grandfather had worked as a fishing guide, and b) mother's measured and estimated umbilical cord blood and childhood hair Hg and her fish consumption during pregnancy with this child. Structural equation modeling (SEM) was used to examine significant links from grandparents (G0) to mothers' exposure and mental health (G1) and children/youth (G2) risk for attempted suicide. RESULTS: Mothers' (G1) median age was 33 y, 86.3% of grandmothers (G0) had lived in Grassy Narrows territory during their pregnancy, and 52.5% of grandfathers (G0) had worked as fishing guides. Sixty percent of children (G2) were <12 years of age. Mothers reported that among teenagers (G2: 12-17 years of age), 41.2% of girls and 10.7% of boys had ever attempted suicide. The SEM suggested two pathways that significantly linked grandparents (G0) to children's (G2) attempted suicides: a) through mothers' (G1) prenatal and childhood Hg exposure and psychological distress, and b) through maternal fish consumption during pregnancy (G1/G2), which is an important contributor to children's emotional state and behavior. DISCUSSION: Despite minimal individual information on G0 and G1 past life experiences, the findings support the hypothesis that Hg exposure over three generations contributes to the mental health of today's children and youth. The prevalence of Grassy Narrows youth ever having attempted suicide is three times that of other First Nations in Canada. [ABSTRACT FROM AUTHOR]

This statement defines probiotics and reviews the most recent literature on their use in paediatrics. Many studies have examined the potential benefit of probiotics, but significant variation in the strains and doses of probiotics used, the patient populations studied, and in study design, have led to heterogeneous results. Present evidence suggests that probiotics can decrease mortality and lower incidence of necrotizing enterocolitis in preterm and low birth weight neonates. Probiotics may also be beneficial in reducing feeding intolerance. In infants, probiotics may be considered to reduce symptoms of colic. In older children, probiotics can be considered to prevent antibiotic-associated diarrhea and Clostridium difficile -associated diarrhea. Probiotic supplements used in conjunction with standard therapy can help with Helicobacter pylori eradication and decrease the side effects of treatment. Lactobacillus species can be considered to treat irritable bowel syndrome. Probiotics can also be considered to help prevent atopic dermatitis and eczema. To optimize paediatric policy and practice, large, quality studies are needed to determine what types and combinations of probiotics are most efficacious. [ABSTRACT FROM AUTHOR]

Background: Obstructive sleep apnea frequently persists in children following adenotonsillectomy, which is the first-line treatment recommended for obstructive sleep apnea with adenotonsillar hypertrophy. Drug-induced sleep endoscopy (DISE) is a diagnostic tool increasingly used to assess pediatric obstructive sleep apnea, but its use has not been standardized. The overarching goal of this study was to document the current practice of Canadian otolaryngologists managing this population. Methods: A nation-wide online cross-sectional survey of Canadian otolaryngologist members of the Canadian Society of Otolaryngology – Head and Neck Surgery and the Association d'otorhinolaryngologie et chirurgie cervico-faciale du Québec. The 58-question electronic survey was developed based on a validated survey redaction guide with the aim to assess management and treatment of pediatric obstructive sleep apnea, as well as indications and performance of DISE. Consensus on practice items was defined by a minimum of 75% similar answers. Results: One hundred and nine Canadian otolaryngologists completed the survey on management of pediatric obstructive sleep apnea, among which 12 of them completed the questions on DISE. Overall, there was a poor rate of agreement of 55% among the respondents for the 58 questions altogether. There was a consensus to assess pediatric obstructive sleep apnea clinically ± with videos (82.6%), to assess adenotonsillar hypertrophy clinically (93.6%) and with flexible scope in the office (80.7%), as well as for the airway sites examined endoscopically during DISE. However, there was no consensus regarding anesthetic protocol and scoring system. DISE was mostly performed in cases of persistent obstructive sleep apnea after adenotonsillectomy rather than before performing any surgical procedure. There was no difference in the management of obstructive sleep apnea between otolaryngologists who perform DISE and those who do not. The only difference between otolaryngologists who practice in community centers versus in tertiary care centers was the more frequently use of the Brodsky tonsil scale by the latter ones. Conclusion: This Canadian-wide survey highlighted a lack of consensus in the management of pediatric obstructive sleep apnea and DISE. Certain aspects regarding DISE remain unclear, including establishment of its ideal timing in order to eventually avoid unnecessary tonsillectomies. [ABSTRACT FROM AUTHOR]

For children with autism spectrum disorder (ASD), a lifelong neurodevelopmental condition, assessment and treatment services vary widely across Canada—potentially creating inequities. To highlight this, the Preschool Autism Treatment Impact study compared children's services and outcomes in New Brunswick (NB) and Nova Scotia (NS). Diagnostic practices, service delivery models, wait times, and treatment approaches differed, as did children's 1-year outcomes and costs for families and the public sector. Considering NB and NS strengths, we suggest that an optimal system would include: rapid access to high-quality diagnostic and intervention services; adherence to research-informed practice guidelines; interventions to enhance parents' skills and self-efficacy; and measures to minimize financial burdens for families. Our results also suggest that provinces/territories must do more to ensure equitable access to effective services, including sharing and reporting on national comparative data. Canadian children with ASD deserve access to effective and consistent services, no matter where they live. [ABSTRACT FROM AUTHOR]

Background We assess the impact of the 2017 American Academy of Pediatrics (AAP) guidelines on the prevalence of high blood pressure (BP) in generally healthy Canadian children and identify risk factors associated with high BP (elevated, stage 1, or stage 2 at a single visit). Methods A cohort of 7,387 children aged 6 to 18 years in the Canadian Health Measures Survey (CHMS, 2007 to 2015) had BPTru oscillometry with centiles and stages assigned using both the 2017 AAP guidelines and the 2004 Fourth Report from the National Institute of Health/National Heart Lung and Blood Institute (NIH/NHLBI). Results Although both shifted upwards significantly, mean population systolic BP and diastolic BP percentiles are now 24.2 (95% confidence interval: 23.3 to 25.2) and 46.4 (45.3 to 47.6). As a result, the population prevalence of high BP increased from 4.5% (3.9 to 5.2, NIH/NHLBI) to 5.8% (5.0 to 6.6, AAP), less than in US children measured by auscultation (14.2%, 13.4 to 15.0). Children with high BP were more likely to be overweight/obese, to be exposed to prenatal/household smoking, and to have hypertriglyceridemia, without differences in dietary salt, infant breastfeeding, neonatal hospitalizations, or exercise frequency. Conclusion The 2017 AAP guidelines increase the prevalence of high BP in Canadian children; Canadian prevalence appears lower than in the USA. This may reflect differences in measurement methods or in the prevalence of childhood overweight/obesity between countries, that is, 31.1% (28.9 to 33.3) versus 40.6% (39.5 to 42.0), respectively. Those with high BP were more likely to have other cardiac risk factors, including overweight/obesity, prenatal/household smoking exposure, and hypertriglyceridemia. [ABSTRACT FROM AUTHOR]

Background: The Canadian Assessment of Physical Literacy (CAPL) accurately and reliably assesses the physical literacy level of young children. However, in preliminary analyses ceiling effects were noted among 183 older children. The purposes of this study were to assess the validity of a modified CAPL designed for older children (CAPL 789) and to offer descriptive results. Methods: CAPL 789 assessed the physical literacy of Canadian children in grades 7–9. Data were collected from schools and recreation facilities in the provinces of Alberta and Ontario (Canada), yielding a new sample of 245 participants (129 girls, 13.7 ± 0.9 years). Descriptive statistics were calculated for all CAPL domains. Age and gender effects were examined to support the validity. Results: Physical competence score (/32) increased with age (F = 4.90, p < 0.05), the means in grades 7–9 being 18.9 ± 3.2, 20.9 ± 4.4 and 21.2 ± 3.4, respectively. Girls scored significantly higher (t = −2.29, p < 0.05) than boys (6.6 ± 1.2 vs 6.3 ± 1.3) in the knowledge assessment (/10). Conclusion: The CAPL 789 was feasible among children from grades 7–9. Additional research is required to establish the psychometric properties in children 12 to 16 years. [ABSTRACT FROM AUTHOR]

BACKGROUND: The objective of this study was to examine individual and concurrent associations between meeting the Canadian 24-Hour Movement Guidelines for Children and Youth (9-11 hours of sleep per night, ≤2 hours of recreational screen time (ST) per day, and at least 60 minutes of moderate to vigorous physical activity per day) and dimensions of impulsivity. METHODS: Data from this cross-sectional observational study were part of the first annual curated release of the Adolescent Brain Cognitive Development Study. Participants included 4524 children between the ages of 8 and 11 years. RESULTS: In analyses, it was shown that adherence to individual movement behavior recommendations as well as combinations of adherence to movement behavior recommendations were associated with each dimension of impulsivity. Meeting all 3 movement behavior recommendations was associated with lower positive urgency (95% confidence interval [CI]: -0.12 to -0.05), negative urgency (95% CI: -0.04 to -0.08), Behavioral Inhibition System (95% CI: -0.08 to -0.01), greater perseverance (95% CI: 0.09 to 0.15), and better scores on delay-discounting (95% CI: 0.57 to 0.94). Meeting the ST and sleep recommendations was associated with less impulsive behaviors on all dimensions of impulsivity: negative urgency (95% CI: -0.20 to -0.10), positive urgency (95% CI: -0.16 to -0.08), perseverance (95% CI: 0.06 to 0.15), Behavioral Inhibition System (95% CI: -0.15 to -0.03), Behavioral Activation System (BAS) reward responsiveness (95% CI: -0.04 to -0.05), BAS drive (95% CI: -0.14 to -0.06), BAS fun-seeking (95% CI: -0.15 to -0.17), and delay-discounting task (95% CI: 0.68 to 0.97). CONCLUSIONS: Findings support efforts to determine if limiting recreational ST while promoting adequate sleep enhances the treatment and prevention of impulsivity-related disorders. [ABSTRACT FROM AUTHOR]

BACKGROUND: Antimicrobial stewardship programs (ASPs) are targeted to optimize antimicrobial use. However, pediatric metrics used to measure outcomes of ASPs are not well established. Our aim for this project was to identify, refine, and develop consensus on standard metrics for pediatric ASPs. METHODS: By using a modified Delphi process, 2 surveys were sent to experts and stakeholders to establish consensus on the utility of metrics. These were subdivided into 4 ASP domains: (1) antimicrobial consumption, (2) microbiologic outcomes, (3) clinical outcomes, and (4) process measures. Respondents were asked to rank the scientific merit, impact, feasibility, and accountability of each metric. Metrics with ≥75% agreement for scientific merit were included and metrics with ≤25% agreement were discarded. Consensus was finalized with a face-to-face meeting and final survey. RESULTS: Thirty-eight participants from 15 pediatric hospitals across Canada completed all 3 rounds of the Delphi survey. In the domain of antimicrobial consumption, the 2 selected metrics were (1) days of therapy per 1000 patient-days and (2) total antimicrobial days. The clinical and process outcomes chosen were (1) 30-day readmission rate and (2) adherence to ASP recommendations, respectively. A microbiologic outcome was felt to be important and feasible, but consensus could not be obtained on a measure. Several barriers to implementation of the metrics were identified, including information technology limitations at various centers. CONCLUSIONS: We obtained consensus on 4 metrics to evaluate pediatric antimicrobial stewardship activities in Canada. Adoption of these metrics by pediatric ASPs will facilitate measurement of outcomes nationally and internationally. [ABSTRACT FROM AUTHOR]

The article offers information on role of the measles vaccine for travelling infants 6 to 11 months of age in the era of global outbreaks of disease. Topics include the measles is a highly contagious and potentially fatal viral illness acquired through a respiratory route that is characterized by cough, coryza, conjunctivitis, and a maculopapular rash, and the complications of infection include pneumonia, acute encephalitis, late-onset subacute sclerosing panencephalitis, and even death.

Objective: Despite a growing number of injuries, no studies exist to date that quantitatively assess the strangulation risk of amber teething necklaces. The objectives of this study are to determine (a) if these necklaces release with the force required according to the American Society for Testing and Materials (ASTM) Standard Specification for Consumer Product Safety for Mechanical Requirements of Children's Jewelry, and (b) if they release with the mean force required to occlude a young child's airway, as determined in a study designed to inform manufacturing of products to reduce risk of accidental strangulation. Methods: Fifteen amber teething necklaces were purchased from retailers in Atlantic Canada. Necklaces were tested using the Breakaway Tension Test method reported in ASTM guidelines. Necklaces were tested with a 15 pound weight (industry standard) and with a 1.6 pound weight (mean force required to occlude a child's airway). It was recorded whether the necklace released or remained intact at the end of each trial. Results: Seven of fifteen necklaces did not open with 15 lbs of force. Eight of 10 necklaces tested did not open with 1.6 lbs of force. Conclusion: Almost 50% of our sample failed to open with 15 pounds of force, which is the force used in the ASTM standard for children's jewelry. Eighty per cent of our sample failed to open with 1.6 pounds of force, which was the mean force to occlude a young child's airway in a published study. These necklaces pose a strangulation risk to young children if they were to become caught. [ABSTRACT FROM AUTHOR]

Background: Canada has recently released guidelines that include toddler-specific recommendations for physical activity, screen-based sedentary behaviour, and sleep. This study examined the proportions of toddlers meeting the new Canadian 24-Hour Movement Guidelines for the Early Years (0-4 years) and associations with body mass index (BMI) z-scores in a sample from Edmonton, Canada.Methods: Participants included 151 toddlers (aged 19.0 ± 1.9 months) for whom there was complete objectively measured physical activity data from the Parents' Role in Establishing healthy Physical activity and Sedentary behaviour habits (PREPS) project. Toddlers' physical activity was measured using ActiGraph wGT3X-BT monitors. Toddlers' screen time and sleep were measured using the PREPS questionnaire. Toddlers' height and weight were objectively measured by public health nurses and BMI z-scores were calculated using World Health Organization growth standards. Meeting the overall 24-Hour Movement Guidelines was defined as: ≥180 min/day of total physical activity, including ≥1 min/day of moderate- to vigorous-intensity physical activity; no screen time per day (for those aged 12-23 months) or ≤1 h/day of screen time per day (ages 24-35 months); and 11-14 h of sleep per 24-h period. Frequency analyses and linear regression models were conducted.Results: Only 11.9% of toddlers met the overall 24-Hour Movement Guidelines, but this finding was largely driven by screen time. The majority of toddlers met the individual physical activity (99.3%) and sleep (82.1%) recommendations, while only 15.2% of toddlers met the screen time recommendation. No associations were observed between meeting specific and general combinations of recommendations within the guidelines and BMI z-scores.Conclusions: Most toddlers in this sample were meeting physical activity and sleep recommendations but were engaging in more screen time than recommended. Consequently, only a small proportion of toddlers met the overall guidelines. Based on the findings of this study, identifying modifiable correlates of screen time to inform appropriate strategies to reduce screen time appears key for increasing the proportion of toddlers meeting the 24-Hour Movement Guidelines for the Early Years. Future research should examine the associations between meeting the new guidelines and other health indicators. Furthermore, future high-quality studies examining dose-response relationships between movement behaviours and health indicators are needed to inform guideline updates. [ABSTRACT FROM AUTHOR]

Objective: To examine changes in the awareness, use, feasibility, and barriers associated with the Canadian Physical Activity and Sedentary Behaviour Guidelines for Children and Youth ages 0-17 years in a sample of Canadian paediatricians, and to assess tools/resources developed by the Canadian Paediatric Society (CPS). Methods: Practicing paediatricians who were members of the CPS were invited to complete an on-line survey in February 2013. In response to survey findings, the CPS developed and promoted tools/resources to increase and improve paediatricians' counselling of the guidelines. The CPS membership was surveyed again in September-October 2014. Findings are based on responses from 331 and 217 (23% and 16% participation rate) Canadian paediatricians who completed the survey in 2013 and 2014, respectively. Results: No significant differences were observed for awareness, use, or feasibility associated with the physical activity or sedentary behaviour guidelines between 2013 and 2014. However, a lack of knowledge/training was reported as a barrier sometimes/often/always by paediatricians significantly less in 2014 (14%) compared to 2013 (32%). Insufficient motivation/lack of support from parents/caregivers/youth was also reported as a barrier less frequently in 2014 (64%) compared to 2013 (75%) but it was borderline non-significant (P=0.05). Only 9% of paediatricians were unaware of the new CPS tools/resources. Conclusions: The new tools/resources developed by the CPS appeared to reduce some barriers experienced by paediatricians in counselling families about the guidelines. However, this did not appear to translate into greater awareness or use of the guidelines. Continued tool/resource development and training initiatives may be required. [ABSTRACT FROM AUTHOR]

The study objective was to examine whether meeting the new Canadian 24-hour movement guidelines was associated with health indicators in a representative sample of Canadian children and youth. Cross-sectional findings are based on 4157 (1239 fasting subsample) children and youth aged 6-17years from cycles 1-3 of the Canadian Health Measures Survey (CHMS). Sleep and screen time were subjectively measured while moderate- to vigorous-intensity physical activity (MVPA) was accelerometer-determined. Health indicators in the full sample (body mass index (BMI) z-scores, waist circumference, blood pressure, behavioral strengths and difficulties score (lower=better), and aerobic fitness) and fasting subsample (triglycerides, high-density lipoprotein (HDL)-cholesterol, C-reactive protein, and insulin) were measured. Meeting the overall guidelines was defined as: 9-11 hour/night (5-13years) or 8-10 hour/day (14-17years) of sleep, ≤2 hour/day of screen time, and ≥60 minute/day of MVPA. Compared to meeting all three recommendations, meeting none, one, and two recommendations were associated with a higher BMI z-score, waist circumference, and behavioral strengths and difficulties score and lower aerobic fitness in a gradient pattern (Ptrend<0.05). Additionally, compared to meeting all three recommendations, meeting none and one recommendation were associated with higher systolic blood pressure and insulin (Ptrend<0.05). Finally, compared to meeting all three recommendations, meeting no recommendations was associated with higher triglycerides and lower HDL-cholesterol (Ptrend<0.05). Collectively, meeting more recommendations within the 24-hour movement guidelines was associated with better overall health. Since a small proportion (17%) of this representative sample was meeting the overall guidelines, efforts to promote adoption are needed. [ABSTRACT FROM AUTHOR]

Background: Despite substantial research on pediatric pain assessment and management, health care professionals do not adequately incorporate this knowledge into clinical practice. Organizational context (work environment) is a significant factor in influencing outcomes; however, the nature of the mechanisms are relatively unknown. The objective of this study was to assess how organizational context moderates the effect of research use and pain outcomes in hospitalized children.Methods: A cross-sectional survey was undertaken with 779 nurses in 32 patient care units in 8 Canadian pediatric hospitals, following implementation of a multifaceted knowledge translation intervention, Evidence-based Practice for Improving Quality (EPIQ). The influence of organizational context was assessed in relation to pain process (assessment and management) and clinical (pain intensity) outcomes. Organizational context was measured using the Alberta Context Tool that includes: leadership, culture, evaluation, social capital, informal interactions, formal interactions, structural and electronic resources, and organizational slack (staff, space, and time). Marginal modeling estimated the effects of instrumental research use (direct use of research knowledge) and conceptual research use (indirect use of research knowledge) on pain outcomes while examining the effects of context.Results: Six of the 10 organizational context factors (culture, social capital, informal interactions, resources, and organizational slack [space and time]) significantly moderated the effect of instrumental research use on pain assessment; four factors (culture, social capital, resources and organizational slack time) moderated the effect of conceptual research use and pain assessment. Only two factors (evaluation and formal interactions) moderated the effect of instrumental research use on pain management. All organizational factors except slack space significantly moderated the effect of instrumental research use on pain intensity; informal interactions and organizational slack space moderated the effect of conceptual research use and pain intensity.Conclusions: Many aspects of organizational context consistently moderated the effects of instrumental research use on pain assessment and pain intensity, while only a few influenced conceptual use of research on pain outcomes. Organizational context factors did not generally influence the effect of research use on pain management. Further research is required to further explore the relationships between organizational context and pain management outcomes. [ABSTRACT FROM AUTHOR]

Background: The Canadian 24-h movement guidelines were developed with the hope of improving health and future health outcomes in children and youth. The purpose of this study was to evaluate adherence to the 3 recommendations most strongly associated with health outcomes in new 24-h movement guidelines and their relationship with adiposity (obesity and body mass index z-score) across countries participating in the International Study of Childhood Obesity, Lifestyle and the Environment (ISCOLE). Methods: Cross-sectional results were based on 6128 children aged 9-11 years from the 12 countries of ISCOLE. Sleep duration and moderate-to-vigorous physical activity (MVPA) were assessed using accelerometry. Screen time was measured through self-report. Body weight and height were measured. Body mass index (BMI, kg ⋅ m-2) was calculated, and BMI z-scores were computed using age- and sex-specific reference data from the World Health Organization. Obesity was defined as a BMI z-score > +2 SD. Meeting the overall 24-h movement guidelines was defined as: 9 to 11 h/night of sleep, ≤2 h/day of screen time, and at least 60 min/day of MVPA. Age, sex, highest parental education and unhealthy diet pattern score were included as covariates in statistical models. Associations between meeting vs. not meeting each single recommendation (and combinations) with obesity were assessed with odds ratios calculated using generalized linear mixed models. A linear mixed model was used to examine the differences in BMI z-scores between children meeting vs. not meeting the different combinations of recommendations. Results: The global prevalence of children meeting the overall recommendations (all three behaviors) was 7%, with children from Australia and Canada showing the highest adherence (15%). Children meeting the three recommendations had lower odds ratios for obesity compared to those meeting none of the recommendations (OR = 0.28, 95% CI 0.18-0.45). Compared to not meeting the 24-h movement recommendations either independently or combined, meeting them was significantly associated with a lower BMI z-score. Whenever the MVPA recommendation was included in the analysis the odds ratios for obesity were lower. Conclusions: For ISCOLE participants meeting these 3 healthy movement recommendations the odds ratios of being obese or having high BMI z-scores were lower. However, only a small percentage of children met all recommendations. Future efforts should aim to find promising ways to increase daily physical activity, reduce screen time, and ensure an adequate night's sleep in children. Trial registration: The International Study of Childhood Obesity, Lifestyle and the Environment (ISCOLE) was registered at ClinicalTrials.gov (Identifier NCT01722500) (October 29, 2012). [ABSTRACT FROM AUTHOR]

Objective: To develop evidence-based guidelines on pharmacotherapy for severe disruptive and aggressive behaviour in children and adolescents with attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), or conduct disorder (CD). The guidelines assume that psychosocial interventions have been pursued but did not achieve sufficient improvement. Method: A multidisciplinary consensus group used the Grading of Recommendations Assessment, Development and Evaluation approach for rating evidence quality and for grading recommendations. We conducted a systematic review of medications studied in placebo-controlled trials for treating disruptive and aggressive behaviour in children and adolescents with ADHD, ODD, or CD. We followed consensus procedures to make 1 of 4 recommendations for each medication: strong, in favour (↑↑); conditional, in favour (↑?); conditional, against (↓.?); and strong, against (↓↓). Results: For children and adolescents with disruptive or aggressive behaviour associated with ADHD, psychostimulants received a strong recommendation in favour of use, while atomoxetine and alpha-2 agonists received a conditional recommendation in favour of use. If these patients do poorly with ADHD medications, the medication with the most evidence is risperidone. Risperidone also has the most evidence for treating disruptive or aggressive behaviour in the absence of ADHD. However, given risperidone's major adverse effects, it received only a conditional recommendation in favour of use. We recommended against using quetiapine, haloperidol, lithium, or carbamazepine because of the poor quality of evidence and their major adverse effects. Conclusion: When severe disruptive or aggressive behaviour occurs with ADHD, medications for ADHD should be used first. Other medications have major adverse effects and, with the exception of risperidone, very limited evidence to support their use. [ABSTRACT FROM AUTHOR]

The article outlines the recommendations from the National Advisory Committee on Immunization (NACI) of Canada for the vaccination of children and youth for the 2014-15 influenza season. It differentiates the two types of influenza vaccines, which are the trivalent inactivated influenza vaccines (TIV) for intramuscular injection and an intranasal, live attenuated influenza vaccine (LAIV). Information on the contraindications to influenza vaccines and the correct dosage of vaccine are presented.

The article presents a discussion on effects probiotics protocols on all-cause mortality and the incidence of necrotizing enterocolitis (NEC) in preterm infants. Topics discussed include use of probiotics in preterm infants; indication for probiotics was based on infant birth weight and gestational age; and indications and contraindications, for health care providers would be beneficial in ensuring safe and consistent practices for probiotic administration.

The authors discusses the paper titled "Diagnosis and Management of Asthma in Preschoolers" developed by the Canadian Thoracic Society (CTS) and the Canadian Paediatric Society (CPS) referring to the term `frequent symptoms' mentioned in the diagnosis and control of asthma.

Background: Recreation and sport facilities often have unhealthy food environments that may promote unhealthy dietary patterns among children. In response, some Canadian provinces have released voluntary nutrition guidelines for recreation and sport facilities, however implementation has been limited. Organizational capacity building may overcome barriers to implementing guidelines. Eat, Play, Live was a randomized controlled trial embedded within a natural experiment that tested the impact of an 18 month capacity building intervention (CBI) in enhancing implementation of provincial nutrition guidelines, and whether nutrition guidelines were associated with positive changes. Primary outcomes were facility capacity, policy development and food environment quality. Methods: Recreation and sport facilities in three guideline provinces were randomized into a guideline + CBI (GL + CBI; n = 17) or a guideline only comparison condition (GL-ONLY; n = 15). Facilities in a province without guidelines constituted a second comparison condition (NO-GL; n = 17). Facility capacity, policy development, and food environment quality (vending and concession) were measured and compared at baseline and follow-up across conditions using repeated measures ANOVA and Chi-square statistics. Healthfulness of vending and concession items was rated as Do Not Sell (least nutritious), Sell Sometimes or Sell Most (most nutritious). Results: There were significant time by condition effects, with significant increases in facility capacity (mean ± SD: 30.8 ± 15.6% to 62.3 ± 22.0%; p < 0.01), nutrition policy development (17.6% developed new policies; p = 0.049), overall quality of the concession food environment (14.7 ± 8.4 to 17.5 ± 7.2; p < 0.001), and in the proportion of Sell Most (3.7 ± 4.4% to 11.0 ± 9.0%; p = 0.002) and Sell Sometimes vending snacks (22.4 ± 14.4% to 43.8 ± 15.8%; p < 0.001) in GL + CBI facilities, with a significant decline in Do Not Sell vending snacks (74.0 ± 16.6% to 45.2 ± 20.1%; p < 0.001). Conclusions: Significant improvements in facility capacity, policy development and food environment quality occurred in recreation and sport facilities that were exposed to nutrition guidelines and participated in a CBI. Outcomes did not improve in facilities that were only passively or not at all exposed to guidelines. Ongoing capacity building may enhance implementation of voluntary nutrition guidelines, however food environments remained overwhelmingly unhealthy, suggesting additional scope to enhance implementation. Trials registration: Clinical trials registration (retrospectively registered): ISRCTN14669997 Jul 3, 2018. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Preventing hospitalizations for respiratory syncytial virus infection" in the August/September 2015 issue.

A response from the author of the article "Preventing hospitalizations for respiratory syncytial virus infection" in the August/September 2015 issue is presented.

The author argues that state requirements for vaccination may further dissuade the public in the U.S. He mentions that public health and pediatric officials are clamoring for a reduction in the number of non-medical exemptions. He explains that this move will only increase the mistrust and resistance. The author cites the herd immunity concept as a tool for forcing parents into rigid adherence to the immunization schedule.