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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.

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 [...]

Objectives: To determine the measurement properties of the Feeding Adequacy Scale (FAS) in young children hospitalized with bronchiolitis., Methods: Multicenter cohort study of infants hospitalized with bronchiolitis at children's and community hospitals in Ontario, Canada. Caregivers and nurses completed the FAS, a 10-cm visual analog scale anchored by "not feeding at all" (score 0) and "feeding as when healthy" (score 10). The main outcome measures were feasibility, reliability, validity, and responsiveness of the FAS., Results: A total of 228 children were included with an average (SD) age of 6.3 (5.4) months. Completing the FAS was feasible for caregivers and nurses, with no floor or ceiling effects. Test-retest reliability was moderate for caregivers (intraclass correlation coefficient [ICC] 2,1 0.73; 95% confidence interval [CI] 0.63-0.80) and good for nurses (ICC 2,1 0.75; 95% CI 0.62-0.83). Interrater reliability between 1 caregiver and 1 nurse was moderate (ICC 1,1 0.55; 95% CI 0.45-0.64). For construct validity, the FAS was negatively associated with length of hospital stay and positively associated with both caregiver and nurse readiness for discharge scores (P values <.0001). The FAS demonstrated clinical improvement from the first FAS score at admission to the last FAS score at discharge, with significant differences between scores for both caregivers and nurses (P values for paired t test <.0001)., Conclusions: These results provide evidence of the feasibility, reliability, validity, and responsiveness of caregiver-completed and nurse-completed FAS as a measure of feeding adequacy in children hospitalized with bronchiolitis., (Copyright © 2023 by the American Academy of Pediatrics.)

Objectives: No previous study has examined the management of hospitalized children with orbital cellulitis at both children's and community hospitals across multiple sites in Canada. We describe variation and trends over time in diagnostic testing and imaging, adjunctive agents, empiric antibiotics, and surgical intervention in children hospitalized with orbital cellulitis., Patients and Methods: Multicenter cohort study of 1579 children aged 2 months to 18 years with orbital cellulitis infections admitted to 10 hospitals from 2009 to 2018. We assessed hospital-level variation in the use of diagnostic tests, imaging, antibiotics, adjunctive agents, surgical intervention, and clinical outcomes using X2, Mann-Whitney U, and Kruskal-Wallis tests. The association between clinical management and length of stay was evaluated with median regression analysis with hospital as a fixed effect., Results: There were significant differences between children's hospitals in usage of C-reactive protein tests (P < .001), computed tomography scans (P = .004), MRI scans (P = .003), intranasal decongestants (P < .001), intranasal corticosteroids (P < .001), intranasal saline spray (P < .001), and systemic corticosteroids (P < .001). Children's hospital patients had significantly longer length of hospital stay compared with community hospitals (P = .001). After adjustment, diagnostic testing, imaging, and subspecialty consults were associated with longer median length of hospital stay at children's hospitals. From 2009 to 2018, C-reactive protein test usage increased from 28.8% to 73.5% (P < .001), whereas erythrocyte sedimentation rate decreased from 31.5% to 14.1% (P < .001)., Conclusions: There was significant variation in diagnostic test usage and treatments, and increases in test usage and medical intervention rates over time despite minimal changes in surgical interventions and length of stay., (Copyright © 2023 by the American Academy of Pediatrics.)

Context: Half of children experience wheezing by age 6 years, and optimal strategies for preventing severe exacerbations are not well defined., Objective: Synthesize the evidence of the effects of daily inhaled corticosteroids (ICS), intermittent ICS, and montelukast in preventing severe exacerbations among preschool children with recurrent wheeze., Data Sources: Medline (1946, 2/25/15), Embase (1947, 2/25/15), CENTRAL., Study Selection: Studies were included based on design (randomized controlled trials), population (children ≤6 years with asthma or recurrent wheeze), intervention and comparison (daily ICS vs placebo, intermittent ICS vs placebo, daily ICS vs intermittent ICS, ICS vs montelukast), and outcome (exacerbations necessitating systemic steroids)., Data Extraction: Completed by 2 independent reviewers., Results: Twenty-two studies (N = 4550) were included. Fifteen studies (N = 3278) compared daily ICS with placebo and showed reduced exacerbations with daily medium-dose ICS (risk ratio [RR] 0.70; 95% confidence interval [CI], 0.61-0.79; NNT = 9). Subgroup analysis of children with persistent asthma showed reduced exacerbations with daily ICS compared with placebo (8 studies, N = 2505; RR 0.56; 95% CI, 0.46-0.70; NNT = 11) and daily ICS compared with montelukast (1 study, N = 202; RR 0.59; 95% CI, 0.38-0.92). Subgroup analysis of children with intermittent asthma or viral-triggered wheezing showed reduced exacerbations with preemptive high-dose intermittent ICS compared with placebo (5 studies, N = 422; RR 0.65; 95% CI, 0.51-0.81; NNT = 6)., Limitations: More studies are needed that directly compare these strategies., Conclusions: There is strong evidence to support daily ICS for preventing exacerbations in preschool children with recurrent wheeze, specifically in children with persistent asthma. For preschool children with intermittent asthma or viral-triggered wheezing, there is strong evidence to support intermittent ICS for preventing exacerbations., (Copyright © 2016 by the American Academy of Pediatrics.)

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.

Context: The degree to which clinical prediction rules (CPRs) for children meet published standards is unclear., Objective: To systematically review the quality, performance, and validation of published CPRs for children, compare them with adult CPRs, and suggest pediatric-specific changes to CPR methodology., Methods: Medline was searched from 1950 to 2011. Studies were selected if they included the development of a CPR involving children younger than 18 years. Two investigators assessed study quality, rule performance, and rule validation as methodologic standards., Results: Of 7298 titles and abstracts assessed, 137 eligible studies were identified. They describe the development of 101 CPRs addressing 36 pediatric conditions. Quality standards met in fewer than half of the studies were blind assessment of predictors (47%), reproducibility of predictors (18%), blind assessment of outcomes (42%), adequate follow-up of outcomes (36%), adequate power (43%), adequate reporting of results (49%), and 95% confidence intervals reported (36%). For rule performance, 48% had a sensitivity greater than 0.95, and 43% had a negative likelihood ratio less than 0.1. For rule validation, 76% had no validation, 17% had narrow validation, 8% had broad validation, and none had impact analysis performed. Compared with CPRs for adult health conditions, quality and rule validation seem to be lower., Conclusions: Many CPRs have been derived for children, but few have been validated. Relative to adult CPRs, several quality indicators demonstrated weaknesses. Existing performance standards may prove elusive for CPRs that involve children. CPRs for children that are more assistive and less directive and include patients' values and preferences in decision-making may be helpful.

Context: Given radiation- and sedation-associated risks, there is uncertainty about which children with head trauma should receive cranial computed tomography (CT) scanning. A high-quality and high-performing clinical prediction rule may reduce this uncertainty., Objective: To systematically review the quality and performance of published clinical prediction rules for intracranial injury in children with head injury., Methods: Medline and Embase were searched in December 2008. Studies were selected if they included clinical prediction rules involving children aged 0 to 18 years with a history of head injury. Prediction-rule quality was assessed by using 14 previously published items. Prediction-rule performance was evaluated by rule sensitivity and the predicted frequency of CT scanning if the rule was used., Results: A total of 3357 titles and abstracts were assessed, and 8 clinical prediction rules were identified. For all studies, the rule derivations were reported; no study validated a rule in a separate population or assessed its impact in actual practice. The rules differed considerably in population, predictors, outcomes, methodologic quality, and performance. Five of the rules were applicable to children of all ages and severities of trauma. Two of these were high quality (>or=11 of 14 quality items) and had high performance (lower confidence limits for sensitivity >0.95 and required or=13). One of these had high quality (11 of 14 quality items) and high performance (lower confidence limit for sensitivity = 0.94 and required 13% to undergo CT). Four of the 8 rules were applicable to young children, but none exhibited adequate quality or performance., Conclusions: Eight clinical prediction-rule derivation studies were identified. They varied considerably in population, methodologic quality, and performance. Future efforts should be directed toward validating rules with high quality and performance in other populations and deriving a high-quality, high-performance rule for young children.

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.