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Innovative therapeutic approaches are needed to alleviate the burden of life-limiting, rare, and chronic conditions affecting children, adolescents, and young adults (CAYA). This includes a need for improved access to both clinical research and to non-approved or off-label therapies, together with, ultimately, more therapies achieving regulatory approval in Canada. The single patient study (SPS), also known as an open label individual patient (OLIP) study, was introduced by Health Canada to open access to non-marketed drugs where a clinical trial is not readily available, but the drug is considered too investigational to be managed on a standard Special Access Program. SPS is designed for patients who have a serious or life-threatening condition and have exhausted available treatment options. Our report summarizes this relatively new development in the Canadian regulatory environment and highlights the opportunities and challenges as identified by regulators, pharmaceutical representatives, academic researchers, and patient/parent advocates. [ABSTRACT FROM AUTHOR]

While paediatric care providers are often the first point of contact for children or youth experiencing mental health challenges, they may lack the resources (e.g. access to a multidisciplinary team) or training to adequately identify or manage such problems. This joint statement describes the key roles and competencies required to assess and address child and youth mental health problems, and the factors that optimize outcomes in this age group. Evidence-informed guidance on screening for and discussing mental health concerns with young people and families is provided. Preventive and therapeutic interventions with demonstrated efficacy in community care settings are discussed. This foundational statement also focuses on the changes to medical education, health systems, and health policy that are needed to improve clinical practice and advocacy efforts in Canada, including appropriate remuneration models, stepped-care approaches, targeted government funding, and professional training and education. [ABSTRACT FROM AUTHOR]

Anxiety disorders are the most common mental health concerns affecting Canadian children and adolescents. The Canadian Paediatric Society has developed two position statements that summarize current evidence regarding the diagnosis and management of anxiety disorders. Both statements offer evidence-informed guidance to support paediatric health care providers (HCPs) making decisions around the care of children and adolescents with these conditions. The objectives of Part 1, which focuses on assessment and diagnosis, are to: (1) review the epidemiology and clinical characteristics of anxiety disorders and (2) describe a process for assessment of anxiety disorders. Specific topics are reviewed, including prevalence, differential diagnosis, co-occurring conditions, and the process of assessment. Approaches are offered for standardized screening, history-taking, and observation. Associated features and indicators that distinguish anxiety disorders from developmentally appropriate fears, worries, and anxious feelings are considered. Note that when the word 'parent' (singular or plural) is used, it includes any primary caregiver and every configuration of family. [ABSTRACT FROM AUTHOR]

Aims To quantify thoracic lymphatic burden in paediatric Fontan patients using MRI and correlate with clinical status. Methods and results Paediatric Fontan patients (<18-years-old) with clinical cardiac MRI that had routine lymphatic 3D T2 fast spin echo (FSE) imaging performed from May 2017 to October 2019 were included. 'Lymphatic burden' was quantified by thresholding-based segmentation of the 3D T2 FSE maximum intensity projection image and indexed to body surface area, performed by two independent readers blinded to patient status. There were 48 patients (27 males) with median age at MRI of 12.9 (9.4–14.7) years, time from Fontan surgery to MRI of 9.1 (5.9–10.4) years, and follow-up time post-Fontan surgery of 9.4 (6.6–11.0) years. Intraclass correlation coefficient between two observers for lymphatic burden was 0.96 (0.94–0.98). Greater lymphatic burden correlated with post-Fontan operation hospital length of stay and duration of chest tube drainage (r s = 0.416, P = 0.004 and r s = 0.439, P = 0.002). Median lymphatic burden was greater in patients with chylous effusions immediately post-Fontan (178 (118–393) vs. 113 (46–190) mL/m2, P = 0.028), and in patients with composite adverse Fontan status (n = 13) defined by heart failure (n = 3), transplant assessment (n = 2), recurrent effusions (n = 6), Fontan thrombus (n = 2), and/or PLE (n = 6) post-Fontan (435 (137–822) vs. 114 (51–178) mL/m2, P = 0.003). Lymphatic burden > 600 mL/m2 was associated with late adverse Fontan status with sensitivity of 57% and specificity of 95%. Conclusion Quantification of MR lymphatic burden is a reliable tool to assess the lymphatics post-Fontan and is associated with clinical status. [ABSTRACT FROM AUTHOR]

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

Background Given the current opioid crisis, caregivers have mounting fears regarding the use of opioid medication in their children. We aimed to determine caregivers' a) willingness to accept, b) reasons for refusing, and c) past experiences with opioids. Methods A novel electronic survey of caregivers of children aged 4 to 16 years who had an acute musculoskeletal injury and presented to two Canadian paediatric emergency departments (ED) (March to November 2017). Primary outcome was caregiver willingness to accept opioids for moderate pain for their children. Results Five hundred and seventeen caregivers participated; mean age was 40.9 (SD 7.1) years with 70.0% (362/517) mothers. Children included 62.2% (321/516) males with a mean age of 10.0 (SD 3.6) years. 49.6% of caregivers (254/512) reported willingness to accept opioids for ongoing moderate pain in the ED, while 37.1% (190/512) were 'unsure'; 33.2% (170/512) of caregivers would accept opioids for at-home use, but 45.5% (233/512) were 'unsure'. Caregivers' primary concerns were side effects, overdose, addiction, and masking of diagnosis. Caregiver fear of addiction (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.01 to 1.25) and side effects (OR 1.25, 95% CI 1.11 to 1.42) affected willingness to accept opioids in the emergency department ; fears of addiction (OR 1.19, 95% CI 1.07 to 1.32), and overdose (OR 1.15, 95% CI 1.04 to 1.27) affected willingness to accept opioids for at-home use. Conclusions Only half of the caregivers would accept opioids for moderate pain, despite ongoing pain following nonopioid analgesics. Caregivers' fears of addiction, side effects, overdose, and masking diagnosis may have influenced their responses. These findings are a first step in understanding caregiver analgesic decision making. [ABSTRACT FROM AUTHOR]

Background Children with adrenal suppression (AS), a potential side effect of glucocorticoids (GCs) may be asymptomatic, present with nonspecific signs and symptoms or with adrenal crisis. Asymptomatic AS (AAS) can only be diagnosed through screening. Identifying and treating asymptomatic patients before symptoms develop may reduce morbidity. Screening guidelines for AS are lacking. Consequently, screening practices are highly variable. Objective To assess (1) the screening practices for and recognition of paediatric AAS among clinicians in Canada and (2) the educational impact of a 2-year surveillance program of symptomatic AS cases. Methods Before and after a 2-year Canadian Paediatric Surveillance Program (CPSP) study of symptomatic AS, participants were surveyed through the CPSP. The prestudy survey was sent to 2,548 participants in March 2010 and the poststudy survey was sent to 2,465 participants in April 2013. Results Response rates were 32% for the prestudy survey and 21% for the poststudy survey. Between the pre- and poststudy surveys, the percentage of physicians who reported routinely screening patients on GCs for AS increased from 10% to 21% and the percentage who reported having a screening policy in their office/centre increased from 6% to 11%. There was no significant change in the percentage of physicians who had diagnosed a child/youth with AAS in the preceding year. Conclusion Frequency of screening for AAS increased following the 2-year study but remains low. Development of a clinical practice guideline should increase both awareness of asymptomatic AS among Canadian paediatricians and the identification of AAS, before symptoms develop. [ABSTRACT FROM AUTHOR]

Objectives Electronic cigarettes and fluid (e-cigarettes, e-fluid) are hazardous materials that when inhaled or ingested may pose significant health risks to children and adolescents. The objective of this work was to explore the spectrum of injury related to e-cigarette exposure among Canadian children and adolescents. Methods A one-time survey was sent to all paediatricians in Canada. Information was collected on children and adolescents who presented with e-cigarette exposure (inhalation and ingestion cases) in the previous 12 months. Questions included the number of injuries and symptoms, in addition to age, sex, treatment setting, intentional e-cigarette use, and how the products were accessed. Results A total of 520 surveys were completed and returned, identifying 35 cases. Symptoms related to inhalation were present in 30 cases and in 5 ingestion cases (5 unintentional, 0 intentional). For inhalation cases, most were male, ages 15 to 19 years, who sought treatment for nausea/vomiting, cough, throat irritation, or acute nicotine toxicity in an outpatient clinic/office. Most inhalation cases reported e-cigarette use 2 to 3 days/week, and e-cigarettes purchases from a mall kiosk/store. For ingestion cases, most were male, ages 1 to 4 years presenting to an emergency department with nausea/vomiting, cough, or respiratory irritation. Younger cases accessed e-fluid at home, older cases purchased in a mall kiosk/store. E-fluid flavours reported consumed were fruit, candy, and tobacco. Conclusions E-cigarettes, recently introduced into the North American market are hazardous to children and adolescents. Given the low response rate to the survey, further investigation into the true burden of injury, as well as the risks that e-cigarettes pose, together with ways to reduce exposure, is needed. [ABSTRACT FROM AUTHOR]

Background Narcolepsy is a sleep disorder with no cure with onset typically during adolescence. Caring for an adolescent with a lifelong medical condition can negatively impact family structure, cohesion, relationships, and overall functioning. The primary objective of this study was to evaluate family functioning in a cohort of adolescents with narcolepsy using the PedsQL Family Impact Module. The secondary objective was to compare family functioning in adolescents with narcolepsy to adolescents with chronic pain based on published data. Methods This was a cross-sectional study of adolescents (aged 10 to 18 years) with narcolepsy. The narcolepsy group was recruited from The Hospital for Sick Children in Toronto, Canada. Family functioning was assessed by the PedsQL family impact module total scores, which was completed by the patient's caregiver. The PedsQL family impact module yields a total scale which encompasses parent health-related quality of life, daily activities, family relationships, communication, and worry subscales. Lower scores suggest poorer family functioning. Secondary data analyses were used to compare participants' family functioning to a cohort of adolescents with chronic pain. Results Thirty adolescents with narcolepsy participated (mean age=13.8 ± 2.2 years, 76.7% male). Family functioning was impaired in this cohort of adolescents with narcolepsy and similar to adolescents with chronic pain (64.0 ± 19.8 versus 64.7 ± 19.5; P=0.849). Conclusion Family functioning is impaired in adolescents with narcolepsy. Clinical teams should assess family functioning at routine clinic visits by asking about concerns and challenges related to caring for an adolescent with narcolepsy and providing resources and support as needed. [ABSTRACT FROM AUTHOR]

Attention-deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder. Three position statements have been developed by the Canadian Paediatric Society, following systematic literature reviews. Statement objectives are to: 1) Summarize the current clinical evidence regarding ADHD, 2) Establish a standard for ADHD care, and 3) Assist Canadian clinicians in making well-informed, evidence-based decisions to enhance care of children and youth with this condition. Specific topics reviewed in Part 3, which focuses on associated autism spectrum disorder, intellectual disability, and prematurity, include the challenges of diagnostic assessment, common presentations, the role of genetics, and treatment, including the benefits of physical activity. Recommendations are based on current guidelines, evidence from the literature, and expert consensus. [ABSTRACT FROM AUTHOR]

Attention-deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder. Three position statements have been developed by the Canadian Paediatric Society, following systematic literature reviews. Statement objectives are to: 1) Summarize the current clinical evidence regarding ADHD, 2) Establish a standard for ADHD care, and 3) Assist Canadian clinicians in making well-informed, evidence-based decisions to enhance care of children and youth with this condition. Specific topics reviewed in Part 1, which focuses on diagnosis, include: prevalence, genetics, pathophysiology, differential diagnosis and comorbid psychiatric disorders and developmental disorders. In addition to database searches, the most recent guidelines of the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, the National Institute for Health and Clinical Excellence, the Scottish Intercollegiate Guidelines Network, and the Eunethydis European ADHD Guidelines Group, were reviewed. Because ADHD is a heterogeneous disorder, comprehensive medical assessment for ADHD should always include a complete history, a physical examination, and a thorough consideration of differential diagnosis and related comorbidities. Specific recommendations for information gathering, testing, and referral are offered. [ABSTRACT FROM AUTHOR]

Attention-deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder. Three position statements have been developed by the Canadian Paediatric Society, following systematic literature reviews. Statement objectives are to: 1) Summarize the current clinical evidence regarding ADHD, 2) Establish a standard for ADHD care, and 3) Assist Canadian clinicians in making well-informed, evidence-based decisions to enhance care of children and youth with this condition. Specific topics reviewed in Part 2, which focuses on treatment, include: evidence and context for a range of clinical approaches, combining behavioural and pharmacological interventions to address impairment more effectively, the role of parent and teacher (or other caregiver) training, the use of stimulant and nonstimulant medications, with effects and risks, and dosing and monitoring protocols. Treatment recommendations are based on current guidelines, evidence from the literature, and expert consensus. [ABSTRACT FROM AUTHOR]

The Canadian Paediatric Society continues to encourage annual influenza vaccination for ALL children and youth ≥6 months of age. Recommendations from the National Advisory Committee on Immunization (NACI) for the 2017/2018 influenza season are not substantially changed from those of last season. NACI has conducted a review of all available vaccine effectiveness data concerning live attenuated influenza vaccine (LAIV) and concludes that current evidence supports the continued use of LAIV in Canada, although use is not currently recommended in the USA because of concern about efficacy. [ABSTRACT FROM AUTHOR]

Introduction: There is evidence that 25-hydroxyvitamin D levels are lower in overweight and obese youth. This study examined the relationship between weight status and 25-hydroxyvitamin D, while controlling for confounders, in Canadian youth. Methods: Plasma 25-hydroxyvitamin D from subjects aged 6 to 17 years from the Canadian Health Measures Survey cycles 1 (2007 to 2009) and 2 (2009 to 2011) was used. Sex-specific multiple linear regression and logistic regressions examined the relationship of overweight and obesity (body mass index = 85th percentile) with 25-hydroxyvitamin D levels and the odds of 25-hydroxyvitamin D <40 nmol/L and <50 nmol/L. Results: The prevalence of risk of vitamin D deficiency (25-hydroxyvitamin D < 30 nmol/L) was 6% (95% confidence interval [CI] 3.26% to 10.12%). Vitamin D inadequacy, estimated by levels <40 nmol/L, was 15% (95% CI 10.34% to 20.39%; 19% [95% CI 13.1 to 25.6] for teenagers). Seventy per cent (95% CI 63.59 to 75.17) had levels >50 nmol/L, consistent with achieving the Recommended Dietary Allowance. In adjusted analyses, overweight/obesity (1/3 of subjects) was independently associated with lower 25-hydroxyvitamin D for both sexes after adjustment for age, race, income, season, vitamin D supplementation and daily milk consumption. For 25-hydroxyvitamin D <40 nmol/L, the overweight/obese odds ratio for males was 2.63 (95% CI 1.34 to 5.18). For 25-hydroxyvitamin D <50 nmol/L, overweight/obese odds ratios were 2.19 (95% CI 1.46 to 3.28) for males and 1.39 (95% CI 1.05 to 1.84) for females. Conclusions: This study confirms the inverse association between adiposity and serum concentrations of 25-hydroxyvitamin D in Canadian youth and the independent association of overweight/obesity to 25-hydroxyvitamin D level and vitamin D status after adjustment for other factors. [ABSTRACT FROM AUTHOR]

Cannabis is the most common illicit drug used worldwide and it is used frequently by Canadian teenagers. Cannabis use during adolescence can cause functional and structural changes to the developing brain, leading to damage. Marijuana use in this age group is strongly linked to: cannabis dependence and other substance use disorders; the initiation and maintenance of tobacco smoking; an increased presence of mental illness, including depression, anxiety and psychosis; impaired neurological development and cognitive decline; and diminished school performance and lifetime achievement. Rates of acute medical care and hospitalization for younger children who have ingested cannabis unintentionally are increasing. Ongoing debate concerning cannabis regulation in Canada makes paying close attention to the evidence for its health effects and ensuring that appropriate safeguards are in place, vital public health priorities. [ABSTRACT FROM AUTHOR]

The article offers information on the efforts for improving paediatric medications for Canadian children and youth. It discusses the policies governing the development, approval and reimbursement of medicines for adult populations; discussions on the need for process redesign for regulatory and reimbursement systems; and the information on the need to expand commercial access for child-friendly formulations.

Canada has witnessed a general decrease in smoking prevalence among all age groups in recent years. However, despite large numbers of campaigns and interventions, thousands of young Canadians continue to initiate cigarette smoking every year. The increasing popularity of alternative tobacco products and e-cigarettes is also creating new health challenges. Research has shown that the deleterious effects of nicotine and cigarette smoke are significant and long lasting. Health care professionals have key responsibilities in preventing tobacco use among youth and their families, and need to know more about effective smoking prevention and cessation strategies. Clinicians need to integrate tobacco counselling into health assessments of teenagers and be aware of the roles that families, communities and governments can play in promoting tobacco-free environments. Information, effective strategies and opportunities for health care professionals to intervene and advocate for Canadian adolescents are discussed. [ABSTRACT FROM AUTHOR]

The effect of active video games (AVGs) on acute energy expenditure has previously been reported; however, the influence of AVGs on other health-related lifestyle indicators remains unclear. To address this knowledge gap, Active Healthy Kids Canada (AHKC) convened an international group of researchers to conduct a systematic review to understand whether AVGs should be promoted to increase physical activity and improve health indicators in children and youth (zero to 17 years of age). The present article outlines the process and outcomes of the development of the AHKC's position on active video games for children and youth. In light of the available evidence, AHKC does not recommend AVGs as a strategy to help children be more physically active. However, AVGs may exchange some sedentary time for light-to moderate-intensity physical activity, and there may be specific situations in which AVGs provide benefit (eg, motor skill development in special populations and rehabilitation). [ABSTRACT FROM AUTHOR]

Comprehensive clinical management plans for treating depression or anxiety disorders in children and adolescents frequently include the use of selective serotonin reuptake inhibitor (SSRI) medications. This statement reviews empirical data regarding the effectiveness of specific SSRI medications, monitoring guidelines, and potential adverse effects of SSRI use including risk of suicidality. SSRI medications can be effective in treating child and adolescent depression and anxiety disorders. Untreated depressive illness may be more harmful than appropriate use of SSRI medication. Physicians should ensure careful elicitation and documentation of baseline depressive and anxious symptoms before initiating SSRI medication. Following medication initiation, patients should also be closely monitored for potential adverse effects, including suicidal ideation and behaviour. [ABSTRACT FROM AUTHOR]

This practice point provides a framework for initiating investigation in children suspected of having infection with Mycobacterium tuberculosis (Mtb). Some areas in Canada have a high burden of tubercular disease, with Indigenous populations being most at risk. Tuberculosis (TB) can present either as an acute or subacute illness and both primary or reactivation infection can cause pulmonary or multisystem disease. Tuberculin skin tests and interferon-γ release assays can be used to support a suspected diagnosis. TB elimination in Canada is possible but requires improving social determinants of health, one of the major factors contributing to the spread of TB in populations at risk. [ABSTRACT FROM AUTHOR]