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OBJECTIVES: Due to rare but severe adverse events, Health Canada in October 2009 required manufacturers to relabel over-the-counter (OTC) cough and cold medication (CCM) to state that the products should not be used in children METHODS: An interrupted time series study was conducted using data from the TARGet Kids! practice-based research network. A total of 3,515 healthy children 1-5 years of age were recruited from 2008-2011; of these, 1,072 had a cough, cold or flu in the previous month. Parents completed a standardized survey instrument. For the primary analysis, use of OTC CCMs prior to and after October 1,2009 was compared using time series analyses. For the secondary analysis, multivariable logistic regression was used to identify predictors of recent OTC CCM use. RESULTS: OTC CCM use was reported in 222 of 1,072 (20.7%) children with a cough, cold or flu within the previous month. OTC CCM use declined from 22.2% to 17.8% following the October 2009 Health Canada labeling standard (p = 0.014). Maternal age CONCLUSION: Labeling legislation against OTC CCM use for children KEY WORDS: Nonprescription drugs; child; preschool; drug legislation; time series analysis Can J Public Health 2015;106(8):e477-e482 doi: 10.17269/CJPH.106.5148 OBJECTIFS: En raison d'effets secondaires rares mais graves, Sante Canada a exige en octobre 2009 que les fabricants refassent les etiquettes des medicaments en vente libre contre la toux et le rhume (MEVLCTR) pour indiquer que ces produits ne doivent pas etre administres aux enfants de METHODE: Nous avons mene une etude des series chronologiques interrompues a l'aide des donnees de TARGet Kids!, un reseau de recherche fondee sur la pratique. Entre 2008 et 2011, nous avons recrute 3 515 enfants sains ages de 1 a 5 ans; de ce nombre, 1 072 avaient eu une toux, un rhume ou une grippe au cours du mois precedent. Les parents ont rempli un instrument de sondage standardise. Pour l'analyse primaire, nous avons compare l'administration des MEVLCTR avant et apres le 1er octobre 2009 a l'aide d'analyses des series chronologiques. Pour l'analyse secondaire, nous avons utilise la regression logistique multivariee pour reperer les variables predictives de l'utilisation recente de MEVLCTR. RESULTATS: L'utilisation de MEVLCTR a ete declaree pour 222 des 1 072 (20,7 %) enfants ayant eu une toux, un rhume ou une grippe au cours du mois precedent. L'utilisation des MEVLCTR a baisse, passant de 22,2 % a 17,8 %, apres l'imposition de la norme d'etiquetage par Sante Canada en octobre 2009 (p = 0,014). L'age maternel CONCLUSION: La loi sur l'etiquetage des MEVLCTR pour en empecher l'administration aux enfants MOTS CLES: medicaments en vente libre; enfant d'age prescolaire; legislation pharmaceutique; analyse des series chronologiques, There has been much debate about the appropriateness of over-the-counter (OTC) cough and cold medication (CCM) use in young children, such use being a frequent topic of conversation between parents [...]

We describe a case of blastomycosis in an 8-year-old boy with Blastomyces-associated osteomyelitis and possible pulmonary involvement. We also identify 309 cases of blastomycosis in Ontario that were seen during [...]

Objective. To examine whether the helmet status of riding companions (child or adult) influences helmet use by children (5-14 years). Methods. This study is part of a larger prospective observational survey that was conducted in a defined urban region of Toronto, Canada (1990-1997, 1999, and 2001). Trained observers collected data on children who were riding bicycles in April through October each year. Observation sites included school yards, parks, major intersections, and residential streets. Results. Of the 2094 children who were observed riding a bicycle, 50% were riding alone, 36% were riding with at least 1 child companion, and 14% were riding with at least 1 adult companion. Compared with riding alone, children were less likely to wear a helmet when riding with nonhelmeted child companions (relative risk [RR]: 0.29; 95% confidence interval [CI]: 0.22-0.38) and were more than twice as likely to wear a helmet when riding with either helmeted child (RR: 2.18; 95% Ch 1.97-2.42) or adult companions (RR: 2.67; 95% Ch 2.44-2.93). Compared with children who were riding with nonhelmeted child companions, children were more likely to wear a helmet when riding with nonhelmeted adults (RR: 3.93; 95% Ch 2.86-5.40), helmeted adults (RR: 9.18; 95% Ch 7.04-11.98), or helmeted children (RR: 7.49; 95% Ch 5.72-9.82). Adjusted analyses showed no difference between companion helmet status and helmet use by children before and after legislation. Conclusions. Helmeted and nonhelmeted adult riding companions were positively associated with child helmet use. The association between child riding companions and child helmet use was positive for helmeted child riding companions and negative for nonhelmeted child riding companions. Efforts need to be made toward improving adult helmet use and children's perceptions and attitudes toward helmet use. bicycle helmet, children, legislation. ABBREVIATIONS. RR, relative risk; CI, confidence interval; OR, odds ratio., An estimated 7 per 1000 children who are 1 to 14 years of age have a bicycle-related injury each year in the United States. (1) Although fatalities are uncommon (5/100 [...]

Objective. The staff/housestaff hospitalist system has been evaluated in 2 pediatric centers in the United States. In Canada, fewer residents and duty hour restrictions led to the development of a staff-only hospitalist system. The objective of this study was to compare the staff-only pediatric hospitalist system and the staff/ housestaff hospitalist system with respect to traditional outcome measures. Design. This cohort study (staff-only hospitalist system versus staff/housestaff system) used electronic health records data (July 1, 1996, to June 30, 1997) for all admissions (n = 3807) to the general pediatric inpatient unit of an urban, tertiary care, pediatric, teaching hospital in Toronto, Canada. Outcome measures included length of hospital stay, subspecialty consultations, readmission to the hospital, and death during the hospital stay. Results. The median length of hospital stay was reduced by 14% for patients admitted to the staff-only hospitalist system, compared with the staff/housestaff hospitalist system (2.5 and 2.9 days, respectively). This difference remained statistically significant after adjustment for age, gender, and comorbidity. There were no significant differences between the 2 models of care with respect to subspecialty consultation, hospital readmission, or mortality rates. A stratified analysis showed similar findings for the 10 most frequent diagnostic groups. Conclusions. The staff-only hospitalist system was associated with a significant reduction in the hospital length of stay, without evidence of adverse effects on mortality or readmission rates, compared with the staff/ hospitalist system. In the context of recent restrictions on resident duty hours in the United States, these findings may be of interest to pediatric teaching hospitals considering the development of a similar staff-only hospitalist model. Pediatrics 2004;114:1545-1549; hospitalist, resident duty hours. ABBREVIATIONS. HSC, Hospital for Sick Children; CPU, clinical practice unit; CTU, clinical teaching unit; IQR, interquartile range., Despite health care system differences, hospital costs constitute significant proportions of overall health care expenditures in both Canada and the United States. In 1996, Wachter and Goldman (1) described the [...]

Neurofibromatosis type 1 (NF-1) can present with a wide variety of skin, nerve, and bone complications. Multiple hyperpigmented areas are common. An 11-year-old girl saw a doctor for severe blood vessel disease in the right leg, which eventually had to be amputated. This may be an atypical presentation of NF-1. However, pediatricians should be alert to the possibility of widespread blood vessel involvement in children with the disease. Early intervention could possibly allow surgical options other than amputation., Neurofibromatosis type 1 (NF-1), a progressive, multisystem, autosomal dominant disorder affecting ~1 in 3000 individuals, is defined by the presence of at lead two of seven criteria, including multiple hyperpigmented [...]

Subsidizing the purchase of bicycle helmets among low-income families may not increase overall helmet use. Researchers offered the sale of bicycle helmets at a reduced rate of $10 to encourage helmet usage among children of low-income families in Toronto, Canada. Children aged from 5 to 12 years old were observed during 1,800 cycling hours. Over a period of three years, general helmet use increased from 3.4 percent to 28% among low-income and high-income residential areas. However, children in the subsidized low-income area were seen using bicycle helmets at a similarly low rate of 18% compared to other low-income areas without such subsidies. Although helmet sales and ownership increased substantially, the availability of less expensive helmets failed to encourage more active use among low-income children. Alternative methods need to focus on changing the behavior among a higher percentage of children. Upcoming legislation may also increase the rate of wearing bicycle helmets., Objective. We have previously shown that an educational program was not effective in increasing bicycle helmet use in children of low-income families. The objective of this study was to evaluate a combined educational and helmet subsidy program in the same population, while controlling for secular trends. The secondary objective was to complete a third year of surveying children's bicycle hemet use throughout the study community. Design. A prospective, controlled, before-and-after study. Subjects. Bicycling children 5 to 14 years of age from areas of low average family income. Setting. A defined geographic community within a large urban Canadian city. Intervention. In April 1992, students in three schools located in the area of lowest average family income were offered $10 helmets and an educational program; three other low-income areas served as control areas. Main Outcome Measure. Helmet use was determined by direct observation of more than 1800 bicycling children. Results. Nine hundred ten helmets were sold to a school population of 1415 (64%). Reported helmet ownership increased from 10% to 47%. However, observed helmet use in the low-income intervention area was no different from the rate in the three low-income control areas (18% versus 19%). There was no difference in the trend in helmet use during the period of 1990 through 1992 in the intervention area (4% to 18%) compared with the control areas (3% to 19%). Helmet use rates from all income areas have increased from 3.4% in 1990, to 16% in 1991, to 28% in 1992. In 1992, helmet use in the high-income areas was 48% and in the low-income areas was 20%. Conclusions. There has been a trend toward increasing helmet use in all income areas during the 3-year period. Despite encouraging helmet sales and increases in reported helmet ownership, the results of the observational study do not support the efficacy of a helmet subsidy program in increasing helmet use in children residing in areas of low average family income. Strategies to increase helmet use in children of low average family income remain a priority. Pediatrics 1995; 96:283-287; bicycle helmet, low-income families, bicycle-related head injury; subsidy program., Bicycle-related trauma accounts for at least 10% of all injury deaths in school-age children, 5 to 14 years of age.(1) In the province of Ontario, bicycle-related injuries account for 15% [...]

Parent counseling and simulated car rides may not be effective in treating persistent crying in infants. Over a two-week period, 38 healthy infants who cried persistently were assigned randomly to one of three groups. Each of these groups was given an assessment and reassurance from a pediatrician, along with support from a public health nurse. Mothers of those in the first group also received counseling in specific treatment techniques. The second group also received a simulated car ride. The third group received only support and reassurance, and served as the control group. Crying diaries and anxiety questionnaires were completed by the mothers before and after the study. Over time, the infants' in all three groups cried less and less. But management strategies and simulated car rides did not appear to be more effective than support and reassurance.

A school-based, bicycle helmet promotion program may increase helmet use among children from high-income families but not among those from low-income families. Increased helmet use could prevent a significant number of bicycle-related head and neck injuries in children. A study examined the effectiveness of a school-based bicycle helmet promotion program in two high-income and two low-income schools in an urban area of Canada. These schools were compared to 18 that did not have a bicycle helmet promotion program (the control schools). The number of children who used a helmet increased at all of the schools between 1990 and 1991. The increase in helmet use was similar at the low-income schools with and without a helmet promotion program. On the other hand, helmet use by children at the high-income schools rose dramatically after the program compared to high-income children who did not go through the program.

To the Editor.-- Birken and Parkin have performed a useful service in identifying "In which journals will pediatricians find the best evidence for clinical practice?" (Pediatrics 1999;103:941-947). Had they not [...]

Objective. To evaluate the influence of average family income in a geographic area on the effectiveness of helmet legislation on observed helmet use by children (5-14 years). Methods. The study was conducted in East York, a health district of Metropolitan Toronto, in collaboration with the East York Health Unit. In 1996, the total population was 107 822, 11 340 of which were children 5 to 14 years. Census data were used to group the 21 census tracts in East York into 7 geographically distinct areas. The boundaries of these areas are natural barriers to travel, such as expressways, ravines, railway tracks, and hydroelectric power lines. The areas were also ranked according to average family income (based on Statistics Canada data). For analytical purposes, areas were defined as low-, mid-, and high-income areas. Census data profiles of the areas have been previously described. For each consecutive year from 1990 to 1997 inclusive, direct observations of children riding bicycles in East York during the months of April through October were made. In 1995, observations were completed before the introduction of the law on October 1, 1995. Only children who were between 5 and 14 years of age and riding a 2-wheeled bicycle were included in the study. In total, 111 sites across all 7 areas were selected for observation. Observational sites included school yards of all elementary and middle schools (kindergarten to grade 8) and all parks in East York. In addition, 5 major intersections and 5 residential streets from each area were randomly selected. Observers were trained and used a standardized data collection form. A pilot study showed that the data collected by observers were reliable and valid. Observers remained at each site for 1 hour and collected data on helmet use and sex. Ethical approval for the study was obtained from the Hospital for Sick Children Research Ethics Board, the East York Board of Education, and the Metropolitan Separate School Board. The proportion of children who were wearing a bicycle helmet was estimated by year (1990-1997, inclusive), sex (male, female), location (school, park, major intersection, residential street), and income area (low, mid, high). For estimating the effect of legislation on helmet use, data from the year immediately after legislation (1996) were compared with data from the year preceding legislation (1995). The relative risk (RR) of helmet use (after vs before legislation) was calculated along with a 95% confidence interval (CI). Logistic regression analysis was used to adjust for potential confounding variables (sex and location). Results. During the 8-year study period, 9768 observations were made (range: 914-1879 observations per year). The proportion of child cyclists who wore a bicycle helmet increased steadily during the first 4 years of the study period, from 4% in 1990 (34 of 914), to 16% in 1991 (303 of 1879), to 25% in 1992 (383 of 1563), and to 45% in 1993 (438 of 984). During 1994 (460 of 1083) and 1995 (568 of 1227), helmet use remained relatively stable at approximately 44%. Helmet use rose markedly in 1996 (the first year after helmet legislation was introduced) to 68% (818 of 1202) and remained stable at 66% (609 of 916) in 1997. Throughout the study period, girls were consistently more likely to wear helmets than were boys. In total, 47% (1420 of 3047) of girls wore helmets, compared with 33% (2193 of 6721) of boys (RR: 1.43; 95% CI: 1.36-1.50). In addition, children who were riding to school were more likely to use helmets, compared with children who were riding on residential streets, major intersections, and parks. Overall, 48% (1497 of 3129) of children who were riding to school wore bicycle helmets, compared with 32% (2116 of 6639) of children who were riding at other locations (RR: 1.50; 95% CI: 1.43-1.58). Children in the high-income areas were consistently more likely to wear helmets, compared with children in the mid-and low-income areas. Helmet legislation was associated with a significant increase in helmet use by children in East York. In 1995, 46% (568 of 1227) of children wore bicycle helmets, compared with 68% (818 of 1202) of children in 1996 (RR: 1.47; 95% CI 1.37-1.58). The effect of legislation, however, varied by income area. In low-income areas, helmet use increased by 28% after legislation, from 33% (213 of 646) in 1995 to 61% (442 of 721) in 1996 (RR: 1.86; 95% CI: 1.64-2.11). In mid-income areas, helmet use increased by 29% after legislation, from 50% (150 of 300) in 1995 to 79% (185 of 234) in 1996 (RR: 1.58; 95% CI: 1.39-1.80). In high-income areas, helmet use increased by only 4%, from 73% (205 of 281) in 1995 to 77% (191 of 247) in 1996 (RR: 1.06; 95% CI: 0.96-1.17). This finding of a significant increase in helmet use after legislation in low-and mid-income areas but not in high-income areas remained even after logistic regression analysis adjusted for sex and location. Conclusions. This study showed that bicycle helmet use by children increased significantly after helmet legislation. In this urban area with socioeconomic diversity and in the context of prelegislation promotion and educational activities, the legislative effect was most powerful among children who resided in low-income areas. Pediatrics 2003;112:e192-e196. URL: http://www. pediatrics.org/cgi/content/full/112/3/e192; socioeconomic status, bicycle helmet, legislation, injury prevention.

Objective. Childhood bicycle-related head injuries can be prevented through the use of helmets. Although helmet legislation has proved to be a successful strategy for the adoption of helmets, its effect on the rates of head injury is uncertain. In Canada, 4 provinces have such legislation. The objective of this study was to measure the impact of helmet legislation on bicycle-related head injuries in Canadian children. Methods. Routinely collected data from the Canadian Institute for Health Information identified all Canadian children (5-19 years) who were hospitalized for bicycling-related injuries from 1994-1998. Children were categorized as head or other injury on the basis of International Classification of Diseases, Ninth Revision, codes. Rates of head injuries and other injuries were compared over time in provinces that adopted legislation and those that did not. Results. Of the 9650 children who were hospitalized because of a bicycle-related injury, 3426 sustained injuries to the head and face and the remaining 6224 had other injuries. The bicycle-related head injury rate declined significantly (45% reduction) in provinces where legislation had been adopted compared with provinces and territories that did not adopt legislation (27% reduction). Conclusion. This country-wide study compared rates of head injury in regions with and without mandatory helmet legislation. Comparing head injuries with other non-head-injured children controlled for potential differences in children's cycling habits. The strong protective association between helmet legislation and head injuries supports the adoption of helmet legislation as an effective tool in the prevention of childhood bicycle-related head injuries. Pediatrics 2002;110(5). URL: http:// www.pediatrics.org/cgi/content/full/110/5/e60; helmet legislation, bicycling injuries, head injuries, pediatrics, prevention.

A number of general medicine and pediatric medical journals are frequently cited as authoritative sources in the development of evidence-based practice guidelines in pediatrics. Researchers reviewed 31 systematic reviews of clinical practices in pediatric medicine and identified the journal articles most often cited in policy statements of the American Academy of Pediatrics, Canadian Pediatric Society, and the Cochrane Database of Systematic Reviews. Four general medical journals from the US and the UK and three pediatric journals were most often cited, indicating that no single journal is the sole authoritative source of evidence-based clinical research, and that pediatric specialty journals do not necessarily outperform general medical journals in the provision of pediatric research., Objective. The objective of this study was to identify the journals that contain the best evidence relating to clinical pediatric practice, thus enabling general pediatricians and pediatric trainees to identify the best quality evidence more efficiently and to select journals for general reading more judiciously. Methods. In the first of three strategies, journal citations from completed systematic reviews using topic headings of pediatric(s), child, infant(s), newborn, neonate(s), neonatology, and adolescent(s) in the Cochrane Database of Systematic Reviews (CDSR) in the 1997, Issue 4, Cochrane Library were collected. In the second strategy, journal citations from American Academy of Pediatrics' (AAP) policy statements from 1994 to 1996 found in the AAP policy reference guide were collected. In the third strategy, journal citations from the Canadian Paediatric Society (CPS) statements from 1990 to 1997 found in Pediatrics and Child Health were collected. Topics related to tertiary neonatology, nonphysician health care professionals, public health policy, ethics, and nonjournal citation sources were excluded. All statements with no references were excluded. Journal citations in CDSR with no pediatric subjects and citation of AAP policy statements cited in AAP policy statements were excluded. The number of citations from the journal cited most frequently, from journals that represented ~10% of all citations and from the 10 journals cited most frequently were expressed as a percent of total citations and a 95% CI was calculated. Results. Using all three strategies (CDSR, AAP, and CPS), the journal cited most frequently was Pediatrics. Using the CDSR strategy (n = 234), citations from Pediatrics represented 6.0% of the total (95% CI: 3.0%, 9.0%), using the AAP strategy (n = 930), citations from Pediatrics represented 11.4% of the total (95% CI: 9.4%, 13.4%), and using the CPS strategy (n = 873), citations from Pediatrics represented 11.9% of the total (95% CI: 9.8, 14.1). Using the CDSR strategy, citations from the 10 journals cited most frequently made up 38.9% of the total citations (95% CI: 32.7%, 45.1%), using the AAP strategy, citations from the 10 journals cited most frequently made up 42.3% of the total citations (95% CI: 39.3%, 45.3%), and using the CPS strategy, citations from the 10 journals cited most frequently made up 60.6% of the total citations (95% CI: 57.4, 63.8). In the CPS strategy, citations from the Journal of Pediatrics represented 10.2% of the total citations (95% CI: 8.2, 12.2) and citations from New England Journal of Medicine represented 9.5% of the total citations (95% CI: 7.6, 11.5). A total of 7 journals were found to be among the 10 cited most frequently using all three strategies (in alphabetical order): Archives of Diseases in Childhood, British Medical Journal, Journal of the American Medical Association, Journal of Pediatrics, Lancet, New England Journal of Medicine, and Pediatrics. Conclusions. This study provides the general pediatrician and pediatric trainee with a strategy to identify efficiently a significant proportion of the best evidence on pediatric practice by restricting searches and reading to a limited number of journals. It also highlights the fact that the best quality evidence on pediatric practice is found in a large number of medical journals. Pediatrics 1999;103:941-947; evidence-based medicine, medical education, clinical pediatrics, information services, bibliometrics., ABBREVIATIONS. CDSR, Cochrane Database of Systematic Reviews; AAP, American Academy of Pediatrics; CPS, Canadian Paediatric Society, HIV, human immunodeficiency virus. The daily care of patients, the continuing education of practicing [...]