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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.

Objectives: To identify sociodemographic, dietary, and biological factors associated with families who do not receive dental care in early childhood and to identify risk factors associated with having cavities among children who receive early dental care., Methods: A cross-sectional study of healthy Canadian children seen for primary health care between September 2011 and January 2013 was conducted through the TARGet Kids! practice-based research network in Toronto, Canada. Adjusted logistic regression was used to determine factors associated with children who were not seen by a dentist in early childhood and to determine risk factors associated with having dental cavities among children who received early dental care., Results: Of the 2505 children included in the analysis, <1% were seen by a dentist by 1 year of age. Older children were less likely to have never been to the dentist (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.87-0.90). Low family income (OR, 2.73; 95% CI, 1.47-5.06), prolonged bottle use (OR, 1.43; 95% CI, 1.03-2.00), and higher intakes of sweetened drinks (OR, 1.20; 95% CI, 1.01-1.42) were associated with increased risk for never having been to the dentist. Among those who had been to the dentist, older children (OR, 1.04; 95% CI, 1.03-1.05), children of low income families (OR, 1.90; 95% CI, 1.17-3.10), and those of East Asian maternal ethnicity (OR, 1.91; 95% CI, 1.10-3.29) were more likely to have dental cavities., Conclusions: Among healthy urban children seen by a primary care provider, those most susceptible to cavities were least likely to receive early dental care. These findings support the need for publicly funded universal early preventive dental care and underscore the importance for primary care physicians to promote dental care in early childhood., (Copyright © 2014 by the American Academy of Pediatrics.)

Objective: To determine whether there is an association between the total breastfeeding duration and iron stores, iron deficiency, and iron deficiency anemia in healthy urban children., Methods: A cross-sectional study of healthy children, aged 1 to 6 years, seen for primary health care between December 2008 and July 2011 was conducted through the TARGet Kids! practice-based research network. Univariate and adjusted regression analyses were used to evaluate an association between total breastfeeding duration and serum ferritin, iron deficiency, and iron deficiency anemia., Results: Included were 1647 healthy children (median age 36 months) with survey, anthropometric, and laboratory data. An association was found between increasing duration of breastfeeding and lower serum ferritin (P = .0015). Adjusted logistic regression analysis revealed the odds of iron deficiency increased by 4.8% (95% confidence interval: 2%-8%) for each additional month of breastfeeding. Exploratory analysis suggested an increasing cumulative probability of iron deficiency with longer total breastfeeding duration with an adjusted odds ratio of 1.71 (95% confidence interval: 1.05-2.79) for iron deficiency in children breastfed over versus under 12 months of age. The relationship between total breastfeeding duration and iron deficiency anemia did not meet statistical significance., Conclusions: Increased total breastfeeding duration is associated with decreased iron stores, a clinically important association warranting additional investigation.

Objective: To examine the association between cow's milk intake on both vitamin D and iron stores in healthy urban preschoolers., Methods: Healthy children 2 to 5 years of age were recruited from December 2008 through December 2010 through the TARGet Kids! practice-based research network. Cow's milk intake was measured by parental report. Vitamin D and iron stores were measured by using serum 25-hydroxyvitamin D and ferritin. Bivariate multivariable linear regression was used to examine the effect of cow's milk intake simultaneously on 25-hydroxyvitamin D and serum ferritin. Analyses were stratified by important clinical variables including skin pigmentation, bottle feeding, vitamin D supplementation, and season., Results: Among 1311 children, increasing cow's milk consumption was associated with decreasing serum ferritin (P < .0001) and increasing 25-hydroxyvitamin D (P ≤ .0001). Two cups (500 mL) of cow's milk per day maintained 25-hydroxyvitamin D >75 nmol/L with minimal negative effect on serum ferritin for most children. Children with darker skin pigmentation not receiving vitamin D supplementation during the winter required 3 to 4 cups of cow's milk per day to maintain 25-hydroxyvitamin D >75 nmol/L. Cow's milk intake among children using a bottle did not increase 25-hydroxyvitamin D and resulted in more dramatic decreases in serum ferritin., Conclusions: There is a trade-off between increasing 25-hydroxyvitamin D and decreasing serum ferritin with increasing milk intake. Two cups of cow's milk per day appears sufficient to maintain healthy vitamin D and iron stores for most children. Wintertime vitamin D supplementation was particularly important among children with darker skin pigmentation.

Objective: We sought to determine the influence of neighborhood income on homicides among children living in urban Canada., Methods: Homicides among children <15 years of age living in any of Canada's census metropolitan areas in 1996, 1997, or 1998 were identified on the basis of vital statistics death registration data, by using International Classification of Diseases, Ninth Revision codes. Deaths were assigned to census tracts through postal codes, and the tracts were then assigned to neighborhood income quintiles on the basis of the proportions of the population below the Statistics Canada low-income cutoff values. Census population counts and intercensal population interpolations were used to estimate person-years at risk for rate calculations. Interquintile rate ratios and 95% confidence intervals were calculated. Poisson regression was used to model the effects of neighborhood income quintiles on homicide rates, after adjustment for age., Results: During the 3-year study period, there were 87 homicides among children <15 years of age in Canada's census metropolitan areas (0.82 cases per 100,000; not statistically different according to gender). The age-adjusted relative risks for the lowest versus highest neighborhood income quintiles were 2.95 for all children <15 years of age and 3.39 for children <5 years of age., Conclusion: Effective child homicide-prevention strategies should be focused on children <5 years of age living in low-income areas.