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

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

Introduction: The authors aimed to examine the association between meeting the integrative movement behavior guidelines (physical activity, screen viewing, and sleep) and cardiometabolic risk (CMR) factors in young children. Methods: In this cross-sectional study, physical activity, screen viewing, and sleep were assessed using parent-reported data. The 24-Hour Movement Guidelines for the Early Years (0–4 y) were defined as 180 minutes of physical activity/day (of which ≥60 min should be moderate-to-vigorous intensity), ≤1 hour of screen viewing/day, and 10 to 13 hours of sleep/night. Waist circumference, glucose, high-density lipoprotein cholesterol, triglycerides, and systolic blood pressure were measured in a clinical setting by trained staff. A total CMR score and individual CMR factors served as primary and secondary outcomes, respectively. Results: Of the 767 participants (3–4 y), 26.4% met none of the guideline's recommendations, whereas 41.3%, 33.1%, and 10.6% of the sample met 1, 2, or all 3 recommendations, respectively. The number of recommendations met was not associated with the total CMR score or individual CMR factors (P >.05), with the exceptions of high-density lipoprotein (odds ratio = 1.61; 95% confidence interval, 1.11 to 2.33; P =.01). Conclusion: Meeting the 24-Hour Movement Guidelines in early childhood was not associated with overall CMR, but was associated with favorable cholesterol outcomes. [ABSTRACT FROM AUTHOR]

Objective: To obtain updated estimates of the incidence and prevalence of neurofibromatosis type 1 (NF1) and type 2 (NF2). Study design: We conducted a systematic search of NF1 and NF2 incidence or prevalence studies, in OVID Medline, OVID Embase, Web of Science, and Cinahl. Studies were appraised with the Joanna Briggs Institute Prevalence Critical Appraisal tool. Pooled incidence and prevalence rates were estimated through random-effects meta-analysis. Results: From 1,939 abstracts, 20 studies were fully appraised and 12 were included in the final review. Pooled NF1 prevalence was 1 in 3,164 (95%CI: 1 in 2,132-1 in 4,712). This was higher in studies that screened for NF1, compared to identification of NF1 through medical records (1 in 2,020 and 1 in 4,329, respectively). NF1 pooled birth incidence was 1 in 2,662 (95%CI: 1 in 1,968-1 in 3,601). There were only 2 studies on NF2 prevalence, so data were not pooled. Pooled NF2 birth incidence was 1.08 per 50,000 births (95%CI: 1 in 32,829-1 in 65,019). Conclusion: We present updated estimates of the incidence and prevalence of NF1 and NF2, to help plan for healthcare access and allocation. The prevalence of NF1 from screening studies is higher than from medical record studies, suggesting that the disease may be under recognized. More studies are needed regarding the prevalence of NF2. [ABSTRACT FROM AUTHOR]

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

Background: Periorbital and orbital cellulitis are inflammatory conditions of the eye that can be difficult to distinguish using clinical examination alone. Computer tomography (CT) scans are often used to differentiate these two infections and to evaluate for complications. Orbital ultrasound (US) could be used as a diagnostic tool to supplement or replace CT scans as the main diagnostic modality. No prior systematic review has evaluated the diagnostic test accuracy (DTA) of ultrasound compared to cross-sectional imaging. Objective: To conduct a systematic review of studies evaluating the DTA of orbital ultrasound compared with cross-sectional imaging, to diagnose orbital cellulitis. Methods: MEDLINE, EMBASE, CENTRAL, and Web of Science were searched from inception to August 10, 2022. All study types were included that enrolled patients of any age with suspected or diagnosed orbital cellulitis who underwent ultrasound and a diagnostic reference standard (i.e., CT or magnetic resonance imaging [MRI]). Two authors screened titles/abstracts for inclusion, extracted data, and assessed the risk of bias. Results: Of the 3548 studies identified, 20 were included: 3 cohort studies and 17 case reports/series. None of the cohort studies directly compared the diagnostic accuracy of ultrasound with CT or MRI, and all had high risk of bias. Among the 46 participants, diagnostic findings were interpretable in 18 (39%) cases which reported 100% accuracy. We were unable to calculate sensitivity and specificity due to limited data. In the descriptive analysis of the case reports, ultrasound was able to diagnose orbital cellulitis in most (n = 21/23) cases. Conclusion: Few studies have evaluated the diagnostic accuracy of orbital ultrasound for orbital cellulitis. The limited evidence based on low quality studies suggests that ultrasound may provide helpful diagnostic information to differentiate orbital inflammation. Future research should focus studies to determine the accuracy of orbital US and potentially reduce unnecessary exposure to radiation. [ABSTRACT FROM AUTHOR]

Background: This study aimed to examine the association between physical activity (PA) and a total cardio metabolic risk (CMR) score in children aged 3-12 years. Secondary objectives were to examine the association between PA and individual CMR factors. Methods: A longitudinal study with repeated measures was conducted with participants from a large primary care practice-based research network in Toronto, Canada. Mixed effects models were used to examine the relationship between parent-reported physical activity and outcome variables (total CMR score, triglycerides, glucose, high-density lipoprotein cholesterol, systolic blood pressure, waist circumference, weight-to-height ratio, and non-high-density lipoprotein cholesterol). Results: Data from 1885 children (6.06 y, 54.4% male) with multiple visits (n = 2670) were included in the analyses. For every unit increase of 60 minutes of PA, there was no evidence of an association with total CMR score (adjusted: -0.02 [-0.014 to 0.004], P = .11]. For the individual CMR components, there was evidence of a weak association between PA and systolic blood pressure (-0.01 [-0.03 to -0.01], P < .001) and waist-to-height ratio (-0.81 [-1.62 to -0.003], P < .001). Conclusion: Parentreported PA among children aged 3-12 years was not statistically associated with total CMR, but was weakly associated with systolic blood pressure and waist-to-height ratio. [ABSTRACT FROM AUTHOR]

Background: There is limited population-based data on Neurofibromatosis type 1 (NF1) in North America. We aimed to develop and validate algorithms using administrative health data and electronic medical records (EMRs) to identify individuals with NF1 in Ontario, Canada.Methods: We conducted an electronic free-text search of 15 commonly-used terms related to NF1 in the Electronic Medical Records Primary Care Database. Records were reviewed by two trained abstractors who classified them as confirmed, possible, and not NF1. An investigator with clinical expertise performed final NF1 classification. Patients were classified as confirmed if there was a documented diagnosis, meeting NIH criteria. Patients were classified as possible if (1) NF1 was recorded in the cumulative patient profile, but no clinical information to support the diagnosis; (2) only one criterion for diagnosis (e.g. child of confirmed case) but no further data to confirm or rule out. We tested different combinations of outpatient and inpatient billing codes, and applied a free-text search algorithm to identify NF1 cases in administrative data and EMRs, respectively.Results: Of 273,440 eligible patients, 2,058 had one or more NF1 terms in their medical records. The terms "NF", "café-au-lait", or "sheath tumour" were constrained to appear in combination with another NF1 term. This resulted in 837 patients: 37 with possible and 71 with confirmed NF1. The population prevalence ranged from 1 in 3851 (confirmed NF1) to 1 in 2532 (possible and confirmed NF1). Billing code algorithms had poor performance, with overall low PPV (highest being 71%). The accuracy of the free-text EMR algorithm in identifying patients with NF1 was: sensitivity 85% (95% CI 74-92%), specificity 100% (95% CI 100-100%), positive predictive value 80% (95% CI 69-88%), negative predictive value 100% (95% CI 100-100%), and false positive rate 20% (95% CI 11-33%). Of false positives, 53% were possible NF1.Conclusions: A free-text search algorithm within the EMR had high sensitivity, specificity and predictive values. Algorithms using billing codes had poor performance, likely due to the lack of NF-specific codes for outpatient visits. While NF1 ICD-9 and 10 codes are used for hospital admissions, only ~ 30% of confirmed NF1 cases had a hospitalization associated with an NF1 code. [ABSTRACT FROM AUTHOR]

Background: The primary aim of this study was to determine if screen use in early childhood is associated with overall vulnerability in school readiness at ages 4 to 6 years, as measured by the Early Development Instrument (EDI). Secondary aims were to: (1) determine if screen use was associated with individual EDI domains scores, and (2) examine the association between screen use and EDI domains scores among a subgroup of high screen users.Methods: This prospective cohort study was carried out using data from young children participating in a large primary care practice-based research network in Canada. Logistic regression analyses were run to investigate the association between screen use and overall vulnerability in school readiness. Separate linear regression models examined the relationships between children's daily screen use and each separate continuous EDI domain.Results: A total of 876 Canadian participants participated in this study. Adjusted logistic regression revealed an association between increased screen use and increased vulnerability in school readiness (p = 0.05). Results from adjusted linear regression demonstrated an association between higher screen use and reduced language and cognitive development domain scores (p = 0.004). Among high screen users, adjusted linear regression models revealed associations between increased screen use and reduced language and cognitive development (p = 0.004) and communication skills and general knowledge domain scores (p = 0.042).Conclusions: Screen use in early childhood is associated with increased vulnerability in developmental readiness for school, with increased risk for poorer language and cognitive development in kindergarten, especially among high users. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: To establish reference intervals for hemoglobin and mean corpuscular volume (MCV) in an ethnically diverse community sample of Canadian children 36 months and younger.Methods: We collected blood samples from young children at scheduled primary care health supervision visits at 2 weeks, 2, 4, 6, 9, 12, 15, 18, 24, and 36 months of age. Samples were analyzed on the Sysmex XN-9000 Hematology Analyzer. We followed the Clinical and Laboratory Standards Institute guidelines in our analysis. Data were partitioned by sex and also combined. We considered large age partitions (3 and 6 months) as well as monthly partitions. Reference intervals (lower and upper limits) and 90% confidence intervals were calculated.Results: Data from 2106 children were included. The age range was 2 weeks to 36 months, 46% were female, 48% were European and 23% were of mixed ethnicity. For hemoglobin, from 2 to 36 months of age, we found a wide reference interval and the 90% confidence intervals indicated little difference across age groups or according to sex. For MCV, from 2 to 7 months of age there was considerable decrease in the reference interval, which was lowest during the second year of life, followed by a slight increase in the last months of the third year of life.Conclusion: These findings suggest adoption of a single hemoglobin reference interval for children 2-36 months of age. Further studies in children under 4 months of age are needed.Trial Registration: TARGet Kids! cohort is registered at ClinicalTrials.gov. www.clinicaltrials.gov . Identifier: NCT01869530 . [ABSTRACT FROM AUTHOR]

Background: Household food insecurity (FI), even at marginal levels, is associated with poor child health outcomes. The Nutrition Screening Tool for Every Preschooler (NutriSTEP®) is a valid and reliable 17-item parent-completed measure of nutrition risk and includes a single item addressing FI which may be a useful child-specific screening tool. We evaluated the diagnostic test properties of the single NutriSTEP® FI question using the 2-item Hunger Vital Sign™ as the criterion measure in a primary care population of healthy children ages 18 months to 5 years.Results: The sample included 1174 families, 53 (4.5%) of which were marginally food secure. An affirmative response to the single NutriSTEP® question "I have difficulty buying food I want to feed my child because food is expensive" had a sensitivity of 85% and specificity of 91% and demonstrated good construct validity when compared with the Hunger Vital Sign™.Conclusion: The single NutriSTEP® question may be an effective screening tool in clinical practice to identify marginal food security in families with young children and to link families with community-based services or financial assistance programs including tax benefits.Trial Registration: TARGet Kids! practice-based research network (Registered June 5, 2013 at www.clinicaltrials.gov ; NCT01869530); www.targetkids.ca. [ABSTRACT FROM AUTHOR]

Several studies have suggested an association between vitamin D in childhood and autism spectrum disorder. No prospective studies have evaluated whether lower vitamin D levels precede ASD diagnoses – a necessary condition for causality. The objective of this study was to prospectively evaluate whether vitamin D serum levels in early childhood was associated with incident physician diagnosed ASD. A prospective cohort study was conducted using data from preschool-aged children in the TARGet Kids! practice-based research network in Toronto, Canada, from June 2008 to July 2015. 25-hydroxyvitamin D concentration was measured through blood samples and vitamin D supplementation from parent report. Autism spectrum disorder diagnosis was determined from medical records at follow-up visits. Covariates included age, sex, family history of autism spectrum disorder, maternal ethnicity, and neighborhood household income. Unadjusted and adjusted relative risks and 95% confidence intervals were estimated using Poisson regression with a robust error variance. In this study, 3852 children were included. Autism spectrum disorder diagnosis was identified in 41 children (incidence = 1.1%) over the observation period (average follow-up time = 2.5 years). An association between 25-hydroxyvitamin D concentration and autism spectrum disorder was not identified in the unadjusted (relative risk = 1.04, 95% confidence interval: 0.97, 1.11 per 10 nmol/L increase in 25-hydroxyvitamin D concentration) or adjusted models (adjusted relative risk = 1.06; 95% confidence interval: 0.95, 1.18). An association between vitamin D supplementation in early childhood and autism spectrum disorder was also not identified (adjusted relative risk = 0.86, 95% confidence interval: 0.46, 1.62). Vitamin D in early childhood may not be associated with incident physician diagnoses of autism spectrum disorder. [ABSTRACT FROM AUTHOR]

Policy has been developed to promote the conduct of high-quality pediatric randomized controlled trials (RCTs). Whether these strategies have influenced publication trends in high-impact journals is unknown. We aim to evaluate characteristics, citation patterns, and publication trends of pediatric RCTs published in general medical journals (GMJs) compared with adult RCTs over a 13-year period. Studies were identified using Medline, and impact metrics were collected from Web of Science and Scopus. All RCTs published from 2005–2018 in 7 GMJs with the highest impact factors were identified for analysis. A random sample of matched pediatric and adult RCTs were assessed for publication characteristics, academic and non-academic citation. Citations were counted from publication until June 2019. Among 4146 RCTs, 2794 (67.3%) enrolled adults, 591 (14.2%) enrolled children, and 761 RCTs (18.3%) enrolled adult and pediatric patients. Adult RCTs published in GMJs grew by 5.1 publications per year (95% CI: 3.3–6.9), while the number of pediatric RCTs did not show significant change (−0.4 RCTs/year, 95% CI: −1.4–0.6). Adult RCTs were cited more than pediatric RCTs (median(IQR): 29.9 (68.5–462.8) citations/year vs. 13.2 (6.8–24.9) citations/year; p < 0.001); however, social media attention was similar (median(IQR) Altmetric Attention Score: 37 (13.75–133.8) vs. 26 (6.2–107.5); p = 0.25). Despite policies which may facilitate conduct of pediatric RCTs, the publishing gap in high-impact GMJs is widening. [ABSTRACT FROM AUTHOR]

Summary: Background: Rapid growth is associated with increased cardiometabolic risk (CMR) in adolescence and adulthood. Little is known about whether the association between rapid growth and increased CMR originates in early childhood. Objectives: To identify age and sex standardized body mass index (zBMI) trajectories and to examine the association between zBMI trajectories and CMR outcomes in children 0 to 60 months. Study design A longitudinal cohort study was conducted through The Applied Research Group for Kids (TARGet Kids!) in Toronto, Canada. Participants had repeated measures of weight and length or height performed from birth to 60 months of age. Latent class mixed modelling was used to identify the zBMI trajectories. Linear regressions were performed to determine the association between zBMI trajectories and the primary outcome, a CMR score, quantified as the sum of age‐ and sex‐ standardized waist circumference, systolic blood pressure, glucose, log‐triglycerides and negative high‐density lipoprotein cholesterol (HDL‐C), divided by √5. Secondary outcomes were the individual components of the CMR formula as well as diastolic blood pressure and non‐HDL‐C. Results: Four BMI trajectories were identified among the 1166 children. After adjusting for all covariates, children in the rapidly accelerating trajectory had increased total CMR score (β = 1.38, 95% CI 0.77; 1.99, P <.001) and increased waist circumference score (β = 2.39, 95% CI 1.92; 2.86, P <.001) compared to the stable low group. Conclusions: Rapid growth during early childhood is associated with increased CMR in preschool children, largely driven by larger waist circumference. [ABSTRACT FROM AUTHOR]

Objectives: While studies exist on the association between screen time and cardiometabolic risk among adolescents, research examining the effect of screen time on cardiometabolic risk in young children is lacking. The primary objective of this study was to examine the association between daily screen time and cardiometabolic risk (CMR) [sum of age- and sex-standardized z-scores of systolic blood pressure (SBP), glucose, log-triglycerides, waist circumference (WC), and negative high-density lipoprotein (HDL) cholesterol divided by the square root of five] in young children. Secondary objectives included examining individual CMR risk factors, including waist-to-height ratio and non high-density lipoprotein (non-HDL) cholesterol, as well as the individual cut-offs of these risk factors. Additional analyses include examining the association between screen time and CMR by handheld/non-handheld devices. Methods: A study was conducted among young children 3 to 6 years from the TARGet Kids! practice-based research network in Toronto and Montreal, Canada. Children with one or more measures of screen time and CMR were included in this study. Generalized estimating equation (GEE) multivariable linear regressions and multivariable logistic regressions, using published cut-offs, were conducted to evaluate these associations. Results: Data from 1317 children [mean age 52 months (SD = 13.36), 44.34% female] were included for analyses. There was no evidence of associations between screen time and total CMR score or individual risk factors (p > 0.05) after adjusting for confounders. A statistically significant, but small association between daily screen time and non-HDL cholesterol was found (B = 0.046; CI = [0.017 to 0.075]; p = 0.002. Conclusions: Though no relationship was reported between daily screen time and the majority of CMR factors in early childhood, there was an association between daily screen time and non-HDL cholesterol. As the relationship between daily screen time and CMR factors may not be apparent in early childhood, studies to evaluate longer-term cardiometabolic effects of screen time are needed. Although there is an evidence-based rationale to reduce screen time in early childhood, prevention of cardiometabolic risk may not be the primary driver. [ABSTRACT FROM AUTHOR]

Numerous oral iron preparations (marketed under a variety of brand names) are available in Canada and are sold without a prescription as natural health products. In cases of nonresponse to iron treatment, the role of iron preparation should be considered, as polysaccharide-iron complex may be less clinically effective than traditionally used ferrous iron preparations. These include heme iron polypeptide (heme [bovine] iron complexed to a protein) and polysaccharide-iron complex preparations (ferric iron, mixed with a saccharide and water, released in the intestinal lumen). Our case highlights important differences between widely available oral iron preparations: polysaccharide-iron complex preparations may be less clinically effective than traditionally used ferrous iron preparations. [Extracted from the article]

Introduction Skin and soft tissue infections of the eye can be classified based on anatomic location as either anterior to the orbital septum (ie, periorbital cellulitis) or posterior to the orbital septum (ie, orbital cellulitis). These two conditions are often considered together in hospitalised children as clinical differentiation is difficult, especially in young children. Prior studies have identified variation in management of hospitalised children with orbital cellulitis; however, they have been limited either as single centre studies or by the use of administrative data which lacks clinical details important for interpreting variation in care. We aim to describe the care and outcomes of Canadian children hospitalised with periorbital and orbital cellulitis. Method and analysis This is a multisite retrospective cohort study including previously healthy children aged 2 months to 18 years admitted to hospital with periorbital or orbital cellulitis from 2009 to 2018. Clinical data from medical records from multiple Canadian hospitals will be collected, including community and academic centres. Demographic characteristics and study outcomes will be summarised using descriptive statistics, including diagnostic testing, antibiotic therapy, adjunctive therapy, surgical intervention and clinical outcomes. Variation will be described and evaluated using χ² test or Kruskal-Wallis test. Generalised linear mixed models will be used to identify predictors of surgical intervention and longer length of stay. Ethics and dissemination Approval of the study by the Research Ethics Board at each participating site has been obtained prior to data extraction. Study results will be disseminated by presentations at national and international meetings and by publications in high impact open access journals. By identifying important differences in management and outcomes by each hospital, the results will identify areas where care can be improved, practice standardised, unnecessary diagnostic imaging reduced, pharmacotherapy rationalised and where trials are needed. [ABSTRACT FROM AUTHOR]

Introduction School readiness is a multidimensional construct that includes cognitive, behavioural and emotional aspects of a child’s development. School readiness is strongly associated with a child’s future school success and well-being. The Early Development Instrument (EDI) is a reliable and valid teacher-completed tool for assessing school readiness in children at kindergarten age. A substantial knowledge gap exists in understanding how early child growth, health behaviours, nutrition, cardiometabolic risk and development impact school readiness. The primary objective was to determine if growth patterns, measured by body mass index trajectories in healthy children aged 0–5 years, are associated with school readiness at ages 4–6 years (kindergarten age). Secondary objectives were to determine if other health trajectories, including health behaviours, nutrition, cardiometabolic risk and development, are associated with school readiness at ages 4–6 years. This paper presents the Fit for School Study protocol. Methods and analysis This is an ongoing prospective cohort study. Parents of children enrolled in the The Applied Health Research Group for Kids (TARGet Kids!) practice-based research network are invited to participate in the Fit for School Study. Child growth, health behaviours, nutrition, cardiometabolic risk and development data are collected annually at health supervision visits and linked to EDI data collected by schools. The primary and secondary analyses will use a two-stage process: (1) latent class growth models will be used to first determine trajectory groups, and (2) generalised linear mixed models will be used to examine the relationship between exposures and EDI results. Ethics and dissemination The research ethics boards at The Hospital for Sick Children, Unity Health Toronto and McMaster University approved this study, and research ethics approval was obtained from each school board with a student participating in the study. The findings will be presented locally, nationally and internationally and will be published in peer-reviewed journals. [ABSTRACT FROM AUTHOR]

Background: Atopic dermatitis (AD) is a chronic inflammatory skin condition characterized by a pruritic eczematous rash. Evidence surrounding the role of serum vitamin D (VD) in modifying disease severity is inconsistent. Objectives: To determine whether VD levels are correlated with AD severity and the effects of VD supplementation on disease modification. Methods: This was a 2-phase study, using a cross-sectional design to evaluate the relationship between VD level and severity, as well as a double-blinded, randomized control trial to elucidate the effects of VD supplementation. Patients aged 0 to 18 years with AD were included in phase 1, and disease severity and serum VD levels were determined. Those with renal, liver, or other dermatologic conditions were excluded. Patients with abnormal (<72.7 nmol/L) VD levels were eligible for phase 2 and to be randomized to either VD supplementation of 2000 IU/d or placebo. VD level and severity were assessed at baseline and 3 months. Results: The 77 patients included in phase 1 had a mean (SD) age of 7.4 (4.5) years, and 45.5% (33/77) were female. Increased severity was significantly correlated with lower VD levels (P = .015). Of the 45 patients included in phase 2, 21 and 24 were assigned to the supplementation and placebo arm, respectively. The mean (SD) change in severity did not differ significantly between the supplementation (15.35 [9.71]) and placebo (15.13 [8.97]) groups after 3 months of intervention (P = .7). Conclusion: Although VD levels correlated with AD severity, VD supplementation did not significantly improve disease severity. [ABSTRACT FROM AUTHOR]

Background: Little is known about nutrition outcomes in preschoolers associated with breastfeeding duration beyond 12 mo of age. Objective: The aim was to examine the association between total breastfeeding duration and nutrition outcomes at 3 to 5 y of age. Design: A cross-sectional study in healthy children, ages 3-5 y, recruited from 9 primary care practices in Toronto was conducted through the TARGet Kids! (The Applied Research Group for Kids) research network. Parents completed standardized surveys, including the Nutrition Screening for Every Preschooler (NutriSTEP) used to assess nutrition risk. Results: A total of 2987 children were included. Ninety-two percent of children were breastfed, and the mean ± SD breastfeeding duration was 11.4 ± 8.4 mo. The prevalence of nutrition risk (score >20) was 17.0%. We examined breastfeeding duration as a continuous variable.With the use of restricted cubic spline modeling, we confirmed a nonlinear relation between breastfeeding duration and NutriSTEP score, dietary intake and eating behavior subscores, and sugar-sweetened beverage and sweet-savory snack consumption. Segmented linear regression was used to examine this nonlinear relation in a piecewise approach. We found a decreasing trend in NutriSTEP score for children who were breastfed for 0-6 mo (β = -0.14; 95% CI: -0.29, 0.004), a significant decrease in NutriSTEP score for children breastfed for 6-12 mo (β = -0.20; 95% CI: -0.33, -0.07), and no significant change after 12 mo (β = 0.09; 95% CI: -0.07, 0.24) and beyond. The mean ± SD NutriSTEP scores were 17.1 ± 7.4 for no breastfeeding, 15.9 ± 6.5 for breastfeeding >0-6 mo, 13.9 ± 6.2 for >6-12 mo, 13.7 ± 6.3 for >12-18 mo, 14.6 ± 6.7 for >18-24 mo, and 14.3 ± 6.8 for >24-36 mo. Conclusions: Breastfeeding for ≤12 mo was associated with decreased nutrition risk and healthier eating behaviors and dietary intake at 3-5 y of age. We found insufficient evidence of additional benefit for breastfeeding beyond 12 mo of age. [ABSTRACT FROM AUTHOR]

Introduction Bronchiolitis is the most common reason for hospitalisation in infants in developed countries. The main focus of hospital care is on supportive care, such as monitoring for hypoxia and supplemental oxygen administration, as active therapies lack effectiveness. Pulse oximetry is used to monitor hypoxia in hospitalised infants and is used either intermittently or continuously. Observational studies have suggested that continuous pulse oximetry use leads to a longer length of hospital stay in stable infants. The use of continuous pulse oximetry may lead to unnecessary clinical intervention due to readings that are of little clinical significance, false-positive readings and less reliance on the clinical status. There is a lack of high-quality evidence to guide which pulse oximetry monitoring strategy, intermittent or continuous, is superior in infants hospitalised with bronchiolitis with respect to patient and policy-relevant outcomes. Methods and analysis This is a multicentre, pragmatic randomised controlled trial comparing two strategies for pulse oximetry monitoring in infants hospitalised for bronchiolitis. Infants aged 1 month to 2 years presenting to Canadian tertiary and community hospitals will be randomised after stabilisation to receive either intermittent or continuous oxygen saturation monitoring on the inpatient unit until discharge. The primary outcome is length of hospital stay. Secondary outcomes include additional measures of effectiveness, acceptability, safety and cost. We will need to enrol 210 infants in order to detect a 12-hour difference in length of stay with a type 1 error rate of 5% and a power of 90%. Ethics and dissemination Research ethics approval has been obtained for this trial. This trial will provide data to guide hospitals and clinicians on the optimal pulse oximetry monitoring strategy in infants hospitalised with bronchiolitis. We will disseminate the findings of this study through peer-reviewed publication, professional societies and meetings. [ABSTRACT FROM AUTHOR]

Background: Accelerated postnatal growth is an important predictor for obesity risk. It is unknown whether early-life obesity-related risk factors affect body mass index (BMI) growth rates during distinct growth periods from early infancy through preschool years. Objective: We examined whether breastfeeding duration, maternal BMI, and birth weight are associated with growth trajectories of age- and sex-standardized WHO BMI z scores (zBMIs) in young children. Design: Children (n = 5905) in The Applied Research Group for Kids (TARGet Kids!) prospective cohort study underwent repeated measures of weight and length or height from birth to 10 y of age. Piecewise linear mixed models were used to determine whether zBMI growth rates differ for each risk factor during periods of growth between birth and 1, 3, 18, 36, and 72 mo of age. Results: Children who were breastfed <6 mo compared with >6 mo showed a higher growth rate between 1-3 and 3-18 mo, resulting in higher standardized BMIs (zBMIs) of +0.24, +0.12, and +0.19 at 18, 36, and 72 mo, respectively. Maternal BMI (in kg/m²) ≥30 compared with <30 resulted in higher growth rates between 1-3 and 36-72 mo and higher zBMIs of +0.22, +0.14, +0.18, and +0.41 at 3, 18, 36, and 72 mo, respectively. Infants weighing <2.5 kg at birth (compared with 2.5-4 kg) experienced higher growth rates between 1-3 and 3-18 mo but had lower zBMIs at all time points (zBMI: -1.45 to -0.21). Infants weighing ≥4 kg at birth (compared with 2.5-4 kg) had significantly lower growth rates in the first 3 mo but higher zBMIs at all time points (zBMI: +1.16 to +0.27). Conclusion: Differences in zBMI growth rates by breastfeeding duration, maternal BMI, and birth weight are seen in early infancy and contribute to differences in zBMI, which persist into midchildhood. [ABSTRACT FROM AUTHOR]

Importance: There is limited evidence that the use of severity of illness scores in pediatric patients can facilitate timely admission to the intensive care unit or improve patient outcomes.Objective: To determine the effect of the Bedside Paediatric Early Warning System (BedsidePEWS) on all-cause hospital mortality and late admission to the intensive care unit (ICU), cardiac arrest, and ICU resource use.Design, Setting, and Participants: A multicenter cluster randomized trial of 21 hospitals located in 7 countries (Belgium, Canada, England, Ireland, Italy, New Zealand, and the Netherlands) that provided inpatient pediatric care for infants (gestational age ≥37 weeks) to teenagers (aged ≤18 years). Participating hospitals had continuous physician staffing and subspecialized pediatric services. Patient enrollment began on February 28, 2011, and ended on June 21, 2015. Follow-up ended on July 19, 2015.Interventions: The BedsidePEWS intervention (10 hospitals) was compared with usual care (no severity of illness score; 11 hospitals).Main Outcomes and Measures: The primary outcome was all-cause hospital mortality. The secondary outcome was a significant clinical deterioration event, which was defined as a composite outcome reflecting late ICU admission. Regression analyses accounted for hospital-level clustering and baseline rates.Results: Among 144 539 patient discharges at 21 randomized hospitals, there were 559 443 patient-days and 144 539 patients (100%) completed the trial. All-cause hospital mortality was 1.93 per 1000 patient discharges at hospitals with BedsidePEWS and 1.56 per 1000 patient discharges at hospitals with usual care (adjusted between-group rate difference, 0.01 [95% CI, -0.80 to 0.81 per 1000 patient discharges]; adjusted odds ratio, 1.01 [95% CI, 0.61 to 1.69]; P = .96). Significant clinical deterioration events occurred during 0.50 per 1000 patient-days at hospitals with BedsidePEWS vs 0.84 per 1000 patient-days at hospitals with usual care (adjusted between-group rate difference, -0.34 [95% CI, -0.73 to 0.05 per 1000 patient-days]; adjusted rate ratio, 0.77 [95% CI, 0.61 to 0.97]; P = .03).Conclusions and Relevance: Implementation of the Bedside Paediatric Early Warning System compared with usual care did not significantly decrease all-cause mortality among hospitalized pediatric patients. These findings do not support the use of this system to reduce mortality.Trial Registration: clinicaltrials.gov Identifier: NCT01260831. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the misclassification resulting from the use of body mass index (BMI) cut-points defined by rounded percentiles instead of Z-scores in early childhood. Using data from the TARGet Kids primary care network we conducted a cross-sectional study among 5836 children < 6 years of age. The World Health Organization growth standards were used to calculate BMI-for-age Z-scores. BMI Z-score cut-points of < - 2.0, > 1.0, > 2.0, > 3.0 are recommended to define wasted, at risk of overweight, overweight and obese. However, rounded percentiles of the 3rd, 85th, 97th, and 99.9th are commonly used. Misclassification was calculated comparing the frequency distributions for BMI categories defined by rounded percentiles and Z-score cut-points. Results: Using rounded percentiles, the proportion of children who were wasted, at risk of overweight, overweight, and obese was 4.2, 12.5, 4.3 and 0.8%, whereas the distribution using Z-scores was: 3.6, 13.8, 3.4 and 1.0%, respectively. Overall, 117 (2%) children were misclassified when using percentiles instead of Z-scores; however, 13% (33/245) of children who were wasted and 14% (8/57) of children who were obese were misclassified. Misclassification of child growth results from the use of cut-points defined by rounded percentiles instead of Z-scores and limits comparability between studies. [ABSTRACT FROM AUTHOR]

Background: Eating habits formed during childhood may contribute to the increasing prevalence of cardiometabolic disorders. Assessing nutritional risk in young children may help to prevent later cardiometabolic disease. The objective of this study was to determine whether parent-reported nutritional risk in preschool-aged children was associated with laboratory indices of cardiometabolic risk, namely leptin and insulin. Methods: In this cross-sectional study, the relationship between nutritional risk as determined by the parentcompleted NutriSTEP® questionnaire was assessed and compared to the serum leptin and insulin concentrations, hormones involved in regulation of food intake and biomarkers of adiposity and cardiometabolic risk. The community-based primary care research network for children in Toronto, Canada (TARGet Kids!) was used. The participants were children aged 3-5 years recruited from TARGet Kids! A total of 1856 children were recruited from seven primary care practices. Of these, 1086 children completed laboratory testing. Laboratory data for leptin and insulin were available for 714 and 1054 of those individuals, respectively. Results: The total NutriSTEP® score was significantly associated with serum leptin concentrations (p = 0.003); for each unit increase in the total NutriSTEP® score, there was an increase of 0.01 ng/mL (95% confidence interval [CI] 0.004-0.018) in serum leptin concentrations after adjusting for potential confounders. The total NutriSTEP® score was not significantly associated with serum insulin concentration. Conclusions: Parent reported nutritional risk is associated with serum leptin, but not insulin, concentrations in preschool-aged children. The NutriSTEP® questionnaire may be an effective tool for predicting future cardiometabolic risk in preschool-aged children. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: Upper respiratory tract infections (URTI) are the most common and costly condition of childhood. Low vitamin D levels have been hypothesized as a risk factor for URTI. The primary objective was to determine if serum vitamin D levels were associated with health-service utilization (HSU) for URTI including hospital admission, emergency department visits and outpatient sick visits. The secondary objectives were to determine whether oral vitamin D supplementation in pregnancy or childhood was associated with HSU for URTI.Design: Cohort study. HSU was determined by linking each child's provincial health insurance number to health administrative databases. Multivariable quasi Poisson regression was used to evaluate the association between 25-hydroxyvitamin D, vitamin D supplementation and HSU for URTI.Setting: Toronto, Canada.Subjects: Children participating in the TARGet Kids! network between 2008 and 2013.Results: Healthy children aged 0-5 years (n 4962) were included; 52 % were male and mean 25-hydroxyvitamin D was 84 nmol/l (range 11-355 nmol/l). There were 105 (2 %), 721 (15 %) and 3218 (65 %) children with at least one hospital admission, emergency department visit or outpatient sick visit for URTI, respectively. There were no statistically significant associations between 25-hydroxyvitamin D or vitamin D supplementation and HSU for URTI.Conclusions: A clinically meaningful association between vitamin D (continuously and dichotomized at <50 and <75 nmol/l) and HSU for URTI was not identified. While vitamin D may have other benefits for health, reducing HSU for URTI does not appear to be one of them. [ABSTRACT FROM AUTHOR]