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The goal of this study was to determine the injury profiles of Canadian children who presented to the Emergency Department from 1990 to 2016 due to an injury caused while traveling in a form of land transportation that did not require child restraint. A case series was conducted using data from the electronic Canadian Hospitals Injury Reporting and Prevention Program (eCHIRPP). Children who were injured while travelling on land transportation for which child restraint is not required, who presented to a Canadian Emergency Department that participates in eCHIRPP between April 1, 1990 to August 29, 2016, were included. Overall, 1856 children sustained 2139 injuries (mean age: 9.8 years (SD 4.5), 45.5% male). The majority of children were injured on a school bus (49.3%). The most commonly injured body part was the head or neck (52.6%). The most common type of injury was a superficial or open wound (33.1%), followed by traumatic brain injury (19.3%). Overall, 39.4% of injuries required no treatment in hospital. Overall, approximately 70 children presented to eCHIRPP EDs per year on a land transportation vehicle that does not require restraints. Biomechanical studies are needed to improve safety on land transportation vehicles that do not require seatbelts.

To examine the prevalence of cervical spine injuries among children and adolescents referred with suspected and diagnosed sports-related concussion (SRC); and evaluate the effect of cervical spine dysfunction (CSD) on physician-documented clinical recovery following SRC.A multidisciplinary pediatric concussion program.A total of 266 patients (6-19 years) referred with suspected SRC.A retrospective cohort study.CSD defined as neurological symptoms localized to the cervical spine or the presence of neck pain, headache, or dizziness and abnormal cervical spine examination findings; physician-documented clinical recovery.One patient was diagnosed with a T1 compression fracture. Of the 246 patients diagnosed with SRC, 80 (32.5%) met the clinical criteria for CSD including 4 patients with central cord neuropraxia and 1 with a spinal cord injury without radiographic abnormality (SCIWORA). Excluding patients with central cord neuropraxia OR SCIWORA, patients with SRC with CSD took longer to achieve physician-documented clinical recovery (28.5 days vs 17 days, P.0001) and were 3.95 times more likely to experience delayed physician-documented clinical recovery (4 weeks postinjury) compared with those without CSD.Patients with suspected and diagnosed SRC can present with a wide spectrum of coincident cervical spine injuries. Cervical spine dysfunction may be a risk factor for delayed clinical recovery.

Sickle cell disease (SCD) is a monogenic hemoglobinopathy associated with significant morbidity and mortality. Cardiopulmonary, vascular and sudden death are the reasons for the majority of young adult mortality in SCD. To better understand the clinical importance of multi-level vascular dysfunction, in 2009 we assessed cardiac function including tricuspid regurgitant jet velocity (TRV), tissue velocity in systole(S') and diastole (E'), inflammatory, rheologic and hemolytic biomarkers as predictors of mortality in patients with SCD. With up to 9 years of follow up, we determined survival in 95 children, adolescents and adults with SCD. Thirty-eight patients (40%) were less than 21 years old at initial evaluation. Survival and Cox proportional-hazards analysis were performed. There was 19% mortality in our cohort, with median age at death of 35 years. In the pediatric subset, there was 11% mortality during the follow up period. The causes of death included cardiovascular and pulmonary complications in addition to other end-organ failure. On Cox proportional-hazards analysis, our model predicts that a 0.1 m/s increase in TRV increases risk of mortality 3%, 1 cm/s increase in S' results in a 91% increase, and 1 cm/s decrease in E' results in a 43% increase in mortality. While excluding cardiac parameters, higher plasma free hemoglobin was significantly associated with risk of mortality (p=.049). In conclusion, elevated TRV and altered markers of cardiac systolic and diastolic function predict mortality in a cohort of adolescents and young adult patients with SCD. These predictors should be considered when counseling cardiovascular risk and therapeutic optimization at transition to adult providers.

Concussion is a form of traumatic brain injury that affects thousands of children and adolescents across Canada annually. With timely access to comprehensive medical care, the majority of patients with acute concussion will recover within 1–4 weeks. Those who develop persistent post-concussion symptoms often benefit from early recognition and referral to multi-disciplinary concussion clinics that have the personnel and resources to meet their complex needs. Youth who live in remote and isolated communities within Canada’s North, a significant proportion of whom are Indigenous, face unique barriers and obstacles to accessing primary and specialised concussion care. Although telemedicine has recently emerged as a tool that can help address these gaps in care, there are presently no clinical guidelines or tools available to assist multi-disciplinary concussion clinics in providing remote concussion care to these medically underserved patients. Here we incorporate literature from a scoping review and our early institutional experience to present an evidence-informed preliminary clinical algorithm and resources to help guide and optimise remote paediatric concussion care delivery in Canada’s North. We also discuss how innovative technologies and partnerships can be leveraged to enhance the delivery of safe, equitable, cost-effective and culturally appropriate care to these communities.

To systematically review published literature on pediatric snowboard injuries, a literature search was performed in PubMed for "snowboard*". Studies must 1) have been primary research; 2) included at least 10 snowboarders; 3) included children and/or adolescents 4) reported specific injury outcomes, risk factors, or injury prevention program effectiveness. The overall injury rates ranged from 0.5 per 1,000 runs to 420 per 1,000 snowboarders. The most common injuries types were fractures, sprains and strains. Most injuries occurred to an upper extremity or the head. Falls and collisions were the most common mechanisms. Snowboarders who were younger, female, had less snowboard experience, or had a previous injury were at greater risk for injury. Wearing wrist guards had a protective effect. Injury rates varied by injury denominator and source of data. Injury prevention efforts should evaluate modifiable extrinsic risk factors, such as strategies to increase use of protective equipment.

OBJECTIVEThe aim of this study was to examine differences in symptom burden and duration until physician-documented clinical recovery among pediatric patients with sports-related concussion (SRC) with and without a history of concussion.METHODSA retrospective chart review was performed for all pediatric patients (7–19 years old) referred to the Pan Am Concussion Program in Winnipeg, Canada, with an SRC and evaluated < 30 days postinjury between September 1, 2013, and August 1, 2015.RESULTSA total of 322 patients with SRC (64.91% male, mean age 13.96 years) who were evaluated a median of 7 days (interquartile range [IQR] 5–11 days) postinjury were included. Patients without a history of concussion endorsed significantly fewer concussion symptoms at initial assessment (median 5.5 symptoms, IQR 1–10 symptoms) than those with a previous concussion (median 7 symptoms, IQR 2–13.25 symptoms; p = 0.036). The median Post-Concussion Symptom Scale scores were 9 (IQR 1–23) for patients with no concussion history and 13 (IQR 3–33) for those with a history of concussion (p = 0.032). For patients with no previous concussion, the median number of days until physician-documented clinical recovery was 23 (IQR 15–44 days) compared with 25 days (IQR 18–43 days) for those with a history of concussion (p = 0.281). There was no significant difference in the proportion of patients who experienced delayed time until physician-documented clinical recovery (> 1 month postinjury) between the groups (p = 0.584).CONCLUSIONSAlthough a history of concussion may be associated with increased symptom burden following pediatric SRC, there was no difference in the time until physician-documented clinical recovery. Pediatric patients with SRC who have a history of concussion should be managed on an individualized basis. Future work is needed to examine the short- and long-term effects of multiple concussions in children and adolescents.

This review examined evidence of the association between maternal pre-pregnancy overweight/obesity status and child neurodevelopmental outcomes. PubMed and PsycINFO databases were systematically searched for empirical studies published before April 2017 using keywords related to prenatal obesity and children's neurodevelopment. Of 1483 identified papers, 41 were included in the systematic review, and 32 articles representing 36 cohorts were included in the meta-analysis. Findings indicated that compared with children of normal weight mothers, children whose mothers were overweight or obese prior to pregnancy were at increased risk for compromised neurodevelopmental outcomes (overweight: OR = 1.17, 95% CI [1.11, 1.24], I2 = 65.51; obese: OR = 1.51; 95% CI [1.35, 1.69], I2 = 79.63). Pre-pregnancy obesity increased the risk of attention deficit-hyperactivity disorder (OR = 1.62; 95% CI [1.23, 2.14], I2 = 70.15), autism spectrum disorder (OR = 1.36; 95% CI [1.08, 1.70], I2 = 60.52), developmental delay (OR = 1.58; 95% CI [1.39, 1.79], I2 = 75.77) and emotional/behavioural problems (OR = 1.42; 95% CI [1.26, 1.59], I2 = 87.74). Given the current obesity prevalence among young adults and women of childbearing age, this association between maternal obesity during pregnancy and atypical child neurodevelopment represents a potentially high public health burden.

Purpose: To examine the safety and tolerability of clinical graded aerobic treadmill testing in recovering adolescent moderate and severe traumatic brain injury (TBI) patients referred to a multidisciplinary pediatric concussion program. Methods: We completed a retrospective case series of two moderate and five severe TBI patients (mean age, 17.3 years) who underwent initial Buffalo Concussion Treadmill Testing at a mean time of 71.6 days (range, 55-87) postinjury. Results: Six patients completed one graded aerobic treadmill test each and one patient underwent initial and repeat testing. There were no complications. Five initial treadmill tests were completely tolerated and allowed an accurate assessment of exercise tolerance. Two initial tests were terminated early by the treatment team because of neurological and cardiorespiratory limitations. As a result of testing, two patients were cleared for aerobic exercise as tolerated and four patients were treated with individually tailored submaximal aerobic exercise programs resulting in subjective improvement in residual symptoms and/or exercise tolerance. Repeat treadmill testing in one patient performed after 1 month of treatment with submaximal aerobic exercise prescription was suggestive of improved exercise tolerance. One patient was able to tolerate aerobic exercise following surgery for posterior glottic stenosis. Conclusions: Preliminary results suggest that graded aerobic treadmill testing is a safe, well tolerated, and clinically useful tool to assess exercise tolerance in appropriately selected adolescent patients with TBI. Future prospective studies are needed to evaluate the effect of tailored submaximal aerobic exercise prescription on exercise tolerance and patient outcomes in recovering adolescent moderate and severe TBI patients.

To examine initial and longitudinal health-related quality of life (HRQOL) in adolescent sports-related concussion (SRC) patients, a prospective observational case-series study was conducted among adolescent SRC patients who were evaluated at a multi-disciplinary pediatric concussion program. Health-related quality of life was measured using the child self-report Pediatric Quality of Life Inventory (PedsQL) generic score scale (age 13-18 version) and the PedsQL Cognitive Functioning scale. Initial and longitudinal HRQOL outcomes were compared between patients who did and did not develop post-concussion syndrome (PCS). A total of 63 patients met the inclusion criteria during the study period. The mean age of the cohort was 14.57 years (standard deviation, 1.17) and 61.9% were male. The median time from injury to initial consultation was 6.5 days (interquartile range, 5, 11). At initial consultation, impairments in physical and cognitive HRQOL but not social or emotional HRQOL were observed. Initial symptom burden and length of recovery were associated with greater impairment in physical and cognitive HRQOL. Patients who went on to develop PCS had significantly worse physical and cognitive HRQOL at initial consultation and demonstrated a slower rate of recovery in these domains, compared with those who recovered in less than 30 days. Adolescent SRC was associated with HRQOL impairments that correlated with clinical outcomes. No persistent impairments in HRQOL were detected among patients who achieved physician-documented clinical recovery. Future studies are needed to evaluate the clinical utility of HRQOL measurement in the longitudinal management of adolescent SRC and PCS patients.

BACKGROUND: Concussion is an emerging public health concern, but care of patients with a concussion is presently unregulated in Canada. METHODS: Independent, blinded Google Internet searches were conducted for the terms "concussion" and "concussion clinic" and each of the Canadian provinces and territories. The first 10 to 15 concussion healthcare providers per province were identified. A critical appraisal of healthcare personnel and services offered on the provider's Web site was conducted. RESULTS: Fifty-eight concussion healthcare providers were identified using this search methodology. Only 40% listed the presence of an on-site medical doctor (M.D.) as a member of the clinical team. Forty-seven percent of concussion healthcare providers advertised access to a concussion clinic, program, or center on their Web site. Professionals designated as team leaders, directors, or presidents among concussion clinics, programs, and centers included a neuropsychologist (15%), sports medicine physician (7%), neurologist (4%), and neurosurgeon (4%). Services offered by providers included baseline testing (67%), physiotherapy (50%), and hyperbaric oxygen therapy (2%). CONCLUSIONS: This study indicates that there are numerous concussion healthcare providers in Canada offering diverse services with clinics operated by professionals with varying levels of training in traumatic brain injury. In some cases, the practices of these concussion clinics do not conform to current expert consensus guidelines. Language: en

OBJECTIVE The objectives of this study were 2-fold: 1) to evaluate the safety, tolerability, and clinical use of graded aerobic treadmill testing in pediatric patients with sports-related concussion (SRC), and 2) to evaluate the clinical outcomes of treatment with a submaximal aerobic exercise program in patients with physiological post-concussion disorder (PCD). METHODS The authors conducted a retrospective chart review of pediatric patients (age < 20 years) with SRC who were referred to a multidisciplinary pediatric concussion program and underwent graded aerobic treadmill testing between October 9, 2014, and February 11, 2016. Clinical assessments were carried out by a single neurosurgeon and included clinical history taking, physical examination, and recording specific patient-reported concussion-related symptoms using the Post-Concussion Symptom Scale (PCSS). Graded aerobic treadmill testing using a modified Balke protocol for incremental increases in intensity was used as a diagnostic tool to assess physiological recovery, classify post-concussion syndrome (PCS) subtype, and reassess patients following treatment. Patients with a symptom-limited threshold on treadmill testing (physiological PCD) were treated with an individually tailored submaximal exercise prescription and multidisciplinary targeted therapies. RESULTS One hundred six patients (mean age 15.1 years, range 11–19 years) with SRC underwent a total of 141 treadmill tests. There were no serious complications related to treadmill testing in this study. Overall, 138 (97.9%) of 141 tests were well tolerated and contributed valuable clinical information. Treadmill testing confirmed physiological recovery in 63 (96.9%) of 65 patients tested, allowing successful return to play in 61 (93.8%). Treadmill testing was used to diagnose physiological PCD in 58 patients and cervicogenic PCD in 1 patient. Of the 41 patients with physiological PCD who had complete follow-up and were treated with tailored submaximal exercise prescription, 37 (90.2%) were classified as clinically improved and 33 (80.5%) successfully returned to sporting activities. Patients who did not respond or experienced an incomplete response to submaximal aerobic exercise treatment included 7 patients with migraine headaches and 1 patient with a postinjury psychiatric disorder. CONCLUSIONS Graded aerobic treadmill testing is a safe, tolerable, and clinically valuable tool that can assist in the evaluation and management of pediatric SRC. Future research is needed to confirm the clinical value of this tool in return-to-play decision making. Studies are also needed to understand the pathophysiology of physiological PCD and the effects of targeted treatment.

Objective: (1) To examine the prevalence of delayed symptom onset (DSO) among pediatric sport-related concussion (SRC) patients as well as the effect of symptom onset on initial symptom severity, length of recovery, and development of delayed recovery; (2) to evaluate the impact of symptom onset on sideline management.Methods: We conducted a prospective study of pediatric SRC patients (

Given the lack of evidence regarding effective pharmacological and non-pharmacological interventions for pediatric mild traumatic brain injury (mTBI) and the resultant lack of treatment recommendations reflected in consensus guidelines, variation in the management of pediatric mTBI is to be expected. We therefore surveyed practitioners across 15 centers in the United States and Canada who care for children with pediatric mTBI to evaluate common-practice variation in the management of pediatric mTBI. The survey, developed by a panel of pediatric mTBI experts, consisted of a 10-item survey instrument regarding providers' perception of common pediatric mTBI symptoms and mTBI interventions. Surveys were distributed electronically to a convenience sample of local experts at each center. Frequencies and percentages (with confidence intervals [CI]) were determined for survey responses. One hundred and seven respondents (71% response rate) included specialists in pediatric Emergency Medicine, Sports Medicine, Neurology, Neurosurgery, Neuropsychology, Neuropsychiatry, Physical and Occupational Therapy, Physiatry/Rehabilitation, and General Pediatrics. Respondents rated headache as the most prevalently reported symptom after pediatric mTBI, followed by cognitive problems, dizziness, and irritability. Of the 65 (61%; [95% CI: 51,70]) respondents able to prescribe medications, non-steroidal anti-inflammatory medications (55%; [95% CI: 42,68]) and acetaminophen (59%; [95% CI: 46,71]) were most commonly recommended. One in five respondents reported prescribing amitriptyline for headache management after pediatric mTBI, whereas topiramate (8%; [95% CI: 3,17]) was less commonly reported. For cognitive problems, methylphenidate (11%; [95% CI: 4,21]) was used more commonly than amantadine (2%; [95% CI: 0,8]). The most common non-pharmacological interventions were rest ("always" or "often" recommended by 83% [95% CI: 63,92] of the 107 respondents), exercise (59%; [95%CI: 49,69]), vestibular therapy (42% [95%CI: 33,53]) and cervical spine exercises (29% [95%CI: 21,39]). Self-reported utilization for common pediatric mTBI interventions varied widely across our Canadian and United States consortium. Future effectiveness studies for pediatric mTBI are urgently needed to advance the evidence-based care.

ObjectivesThe objectives were 1) to compare the effects of adolescent sport-related concussion (SRC) and sport-related extremity fracture (SRF) on academic outcomes including change in school grades and school attendance; and 2) to determine which specific academic accommodations were most helpful during recovery from these injuries.MethodsA prospective cohort study was conducted to compare changes in school grades, school attendance and academic accommodations among students (grades 8-12) with an SRC or SRF. School grades were extracted from student immediate pre- and post-injury report cards. Students completed attendance log books and an exit interview to determine which accommodations were helpful and how accommodating they perceived their school to be during their recovery.ResultsOverall, 124 students (92 with SRC and 32 with SRF) submitted both pre- and post-injury report cards. Students who sustained an SRC or SRF experienced similar decreases in grades post-injury (SRC: -1.0%; 95% CI: -2.1, 0.1 and SRF: -0.9%: 95% CI: -2.1, 0.3). Students with an SRC missed significantly more days of school compared to those with an SRF (median of 4 days [IQR: 1, 7] versus 1 day [IQR: 0, 4], pConclusionsStudents who sustain an SRC miss significantly more days of school but demonstrate similar changes in school grades post-injury compared to those with an SRF. Future studies are needed to identify the pre- and post-injury factors associated with poor academic functioning following concussion and identify measures that can be taken to help optimize academic outcomes in these patients.

Pediatric concussion patients living in northern communities in Canada can face unique challenges accessing primary and specialized healthcare. In this study we report the clinical characteristics, healthcare utilization, outcomes and estimated cost avoidance associated with a pilot pediatric concussion telemedicine program established between a multi-disciplinary pediatric concussion program in Winnipeg, Manitoba and a hospital in Thompson, Manitoba. From October 1st- July 1st, 2018, 20 patients were evaluated; mean age 13.1 years, 15 (75%) males and 14 (70%) self-identified as Indigenous. Injury mechanisms included hockey (50%), falls (35%) and assaults (15%). Median time from referral to initial consultation was 2.0 days. After screening by the neurosurgeon, 90% of patients underwent initial consultation via real-time videoconferencing with 80% managed exclusively through telemedicine. At the end of the study, 90% met the criteria for clinical recovery, one remained in treatment and one was discharged to a headache neurologist. Sixty-six telemedicine encounters were completed including 57 videoconferencing appointments and 9 telephone follow-ups representing an estimated cost avoidance of $40,972.94. This study suggests telemedicine may be a useful approach to assist pediatric concussion programs with delivering timely, safe and cost-effective care to patients living in medically underserviced remote and northern communities in Canada.

Health-related quality of life (HRQOL) is an emerging method to quantify the consequences of pediatric mild traumatic brain injury (mTBI)/concussion in both clinical practice and research. However, to utilize HRQOL measurements to their full potential in the context of mTBI/concussion recovery, a better understanding of the typical course of HRQOL after these injuries is needed. The objective of this study was to summarize current knowledge on HRQOL after pediatric mTBI/concussion and identify areas in need of further research. The following databases from their earliest date of coverage through June 1, 2015 were used: MEDLINE(®), PubMed, Embase, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), SPORTDiscus, Cochrane Central Register of Controlled Trials (CENTRAL), Physiotherapy Evidence Database (PEDro), and Child Development and Adolescent Studies (CDAS). Studies must have examined and reported HRQOL in a pediatric population after mTBI/concussion, using a validated HRQOL measurement tool. Eight of 1660 records identified ultimately met inclusion criteria. Comprehensive data were extracted and checked by a second reviewer for accuracy and completeness. There appears to be a small but important subgroup of patients who experience poor HRQOL outcomes up to a year or longer post-injury. Potential predictors of poor HRQOL include older age, lower socioeconomic status, or a history of headaches or trouble sleeping. Differing definitions of mTBI precluded meta-analysis. HRQOL represents an important outcome measure in mTBI/concussion clinical practice and research. The evidence shows that a small but important proportion of patients have diminished HRQOL up to a year or longer post-injury. Further study on this topic is warranted to determine the typical longitudinal progression of HRQOL after pediatric concussion.

Objectives: The objective of this study was to evaluate the feasibility and implementation of a standardized medically supervised concussion protocol established between a city-wide AAA hockey league and a multi-disciplinary concussion program. Methods: We conducted a retrospective review of injury surveillance, clinical and healthcare utilization data from all athletes evaluated and managed through the Winnipeg AAA Hockey concussion protocol during the 2016-2017 season. We also conducted post-season email surveys of head coaches and parents responsible for athletes who competed in the same season. Results: During the 2016-2017 season, 28 athletes were evaluated through the medically supervised concussion protocol, with two athletes undergoing evaluation for repeat injuries (a total of 30 suspected injuries and consultations). In all, 96.7% of the athletes managed through the concussion protocol were captured by the league-designated Concussion Protocol Coordinator and 100% of eligible athletes underwent complete medical follow-up and clearance to return to full hockey activities. Although 90% of responding head coaches and 91% of parents were aware of the concussion protocol, survey results suggest that some athletes who sustained suspected concussions were not managed through the protocol. Head coaches and parents also indicated that athlete education and communication between medical and sport stakeholders were other elements of the concussion protocol that could be improved. Conclusion: Successful implementation of a medically supervised concussion protocol for youth hockey requires clear communication between sport stakeholders and timely access to multi-disciplinary experts in traumatic brain and spine injuries. Standardized concussion protocols for youth sports may benefit from periodic evaluations by sport stakeholders and incorporation of national guideline best practices and resources.

OBJECTIVEThe longitudinal effects of sports-related concussion (SRC) in adolescents on health-related quality of life (HRQOL) remain poorly understood. Hence, the authors established two objectives of this study: 1) compare HRQOL outcomes among adolescents with an acute SRC or a sports-related extremity fracture (SREF) who were followed up until physician-documented clinical recovery; and 2) identify the clinical variables associated with worse HRQOL among adolescent SRC patients.METHODSThe authors conducted a prospective cohort study of adolescents with acute SRC and those with acute SREF who underwent clinical assessment and follow-up at tertiary subspecialty clinics. Longitudinal patient-reported HRQOL was measured at the time of initial assessment and at each follow-up appointment by using the adolescent version (age 13–18 years) of the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scale and Cognitive Functioning Scale.RESULTSA total of 135 patients with SRC (60.0% male; mean age 14.7 years; time from injury to initial assessment 6 days) and 96 patients with SREF (59.4% male; mean age 14.1 years; time from injury to initial assessment 8 days) participated in the study. At the initial assessment, the SRC patients demonstrated significantly worse cognitive HRQOL and clinically meaningful impairments in school and overall HRQOL compared to the SREF patients. Clinical variables associated with a worse HRQOL among SRC patients differed by domain but were significantly affected by the patients’ initial symptom burden and the development of delayed physician-documented clinical recovery (> 28 days postinjury). No persistent impairments in HRQOL were observed among SRC patients who were followed up until physician-documented clinical recovery.CONCLUSIONSAdolescent SRC is associated with temporary impairments in HRQOL that have been shown to resolve in patients who are followed up until physician-documented clinical recovery. Future studies are needed to identify the clinicopathological features that are associated with impaired HRQOL and to assess whether the initiation of multidisciplinary, targeted rehabilitation strategies would lead to an improvement in HRQOL.

Objective Report the clinical findings and outcomes among pediatric patients diagnosed with benign paroxysmal positional vertigo (BPPV) after sports-related concussion (SRC). Design Retrospective case series. Setting Multidisciplinary pediatric concussion program. Patients Patients younger than 19 years with a sport or recreation activity-related concussion referred for comprehensive vestibular physiotherapy assessment. Main outcome measure Symptom resolution after targeted particle repositioning (PR). Results During the study period, 115 pediatric SRC patients underwent vestibular physiotherapy assessment including 12 (10.4%) who were diagnosed with BPPV. Unilateral posterior semicircular canal (SCC) BPPV was diagnosed in 8/12 (75%) patients, and unilateral anterior SCC BPPV diagnosed in 4/12 (25%) patients. Benign paroxysmal positional vertigo was successfully treated in all patients with a mean of 1.58 targeted PR maneuvers (range = 1-4). Conclusions Comprehensive management of pediatric SRC requires a multidisciplinary approach to address the heterogeneous pathophysiology of persistent postconcussion symptoms. Pediatric SRC patients with coexisting BPPV should be considered for targeted PR.

Aim: The purpose of this study was to examine academic achievement, absenteeism and school accommodations following adolescent sport-related concussion (SRC). Methods: A case-series was conducted among grade 8–12 students who suffered an SRC. The primary outcomes were change in pre- and post-concussion overall, core report card grade point average (GPA) and absenteeism due to concussion. The most helpful school accommodations were tabulated. Results: Pre- and post-concussion GPA was obtained from 33 students – 16 (48%) developed persistent post-concussion symptoms (symptoms lasting >4 weeks). There was no significant difference in pre- and post-concussion grades among students with a SRC for overall (p = 0.75) or core (p = 0.56) GPA. The median number of missed school days was 4 (interquartile range [IQR]: 2–8). Allowing for physical and cognitive rest was identified as the most helpful accommodation (30%). Conclusion: Larger studies should investigate the role that school accommodations and development of persistent post-concussion symptoms have on academic outcomes.

Background The study was designed to determine if youth

Concussion often results in symptoms, including difficulty concentrating, focusing, and remembering, that are typically managed with cognitive and physical rest. Often, the school environment is not conducive to cognitive rest and may lead to worsening or prolonged symptoms that can contribute to impaired academic performance. The objective of the review was to identify and summarize literature concerning the effects of concussion or mild traumatic brain injury (mTBI) on academic outcomes. MEDLINE, Embase, Scopus, and CINAHL were searched until June 1, 2016. Studies must have been primary literature examining students enrolled in primary, secondary, or post-secondary education, have received a physician diagnosis of concussion or mTBI, and have post-injury academic outcomes assessed in numeric or alphabet grade/grade point average (GPA), school attendance records, or national examination scores. Data were extracted and checked by a second reviewer for accuracy and completeness. Nine studies were included. Among four studies that examined grades, one found a significant difference in pre- and post-grades only in the subject Afrikaans. Three examined national test scores and no significant differences were found between cases and controls. Four examined school absenteeism and found that students who developed post-concussion syndrome missed significantly more school days and took longer to return to school than students with extremity injuries. Although mTBI or concussion is associated with missed school, the results demonstrate minimal impact on school grades and national examination scores at a group level. Further research is needed to identify risk factors for impaired school functioning following mTBI and concussion in individual patients.

In this article, we conduct a review of introduced and enacted youth concussion legislation in Canada and present a conceptual framework and recommendations for future youth sport concussion laws. We conducted online searches of federal, provincial, and territorial legislatures to identify youth concussion bills that were introduced or successfully enacted into law. Internet searches were carried out from July 26 and 27, 2016. Online searches identified six youth concussion bills that were introduced in provincial legislatures, including two in Ontario and Nova Scotia and one each in British Columbia and Quebec. One of these bills (Ontario Bill 149, Rowan’s Law Advisory Committee Act, 2016) was enacted into provincial law; it is not actual concussion legislation, but rather a framework for possible enactment of legislation. Two bills have been introduced in federal parliament but neither bill has been enacted into law. At present, there is no provincial or federal concussion legislation that directly legislates concussion education, prevention, management, or policy in youth sports in Canada. The conceptual framework and recommendations presented here should be used to guide the design and implementation of future youth sport concussion laws in Canada.

Background: Sport-related concussion is a form of traumatic brain injury that often presents with a combination of symptoms that reflect disturbances in physical, cognitive, sleep, and emotional functioning. The longitudinal effects of adolescent sports-related concussion (SRC) on health-related quality of life (HRQOL) remain poorly understood. The objectives of this study were to 1) compare HRQOL outcomes among adolescents with an acute SRC or sports-related extremity fracture (SRF) who were followed until physician-documented clinical recovery and 2) to identify the clinical variables associated with worse HRQOL among adolescent SRC patients. Methods: We conducted a prospective cohort study of adolescents with acute isolated SRC or SRF who underwent clinical assessment within 30 days post injury and follow-up at tertiary sub-specialty clinics. Longitudinal patient-reported HRQOL was measured at initial assessment and at each follow-up appointment using the adolescent version (age 13-18) Pediatric Quality of Life Inventory generic core scale and Cognitive Functioning scale. Demographic characteristics were collected from the medical charts. Results: Participants in this study included 135 patients with SRC (60.0% male; mean age 14.7 years; time from injury to initial assessment 6 days) and 96 with SRF (59.4% male, mean age 14.1 years; time from injury to initial assessment 8 days). At initial assessment, SRC patients reported significantly worse cognitive, school and overall HRQOL compared to SRF patients with no differences in physical, emotional and social HRQOL. Clinical variables associated with worse HRQOL among SRC patients differed by domain but were significantly impacted by initial symptom burden and the development of delayed physician-documented clinical recovery (> 28 days post-injury). Overall, 132 (97.8%) SRC patients and all SRF patients achieved physician-documented clinical recovery during the study period. The median days until physician-documented clinical recovery for the SRC patients was 26 days (IQR: 17, 49) and this was not significantly different than SRF patients (31 days, IQR: 23, 42; p=0.12). At the time of physician-documented clinical recovery, patients with SRC did not have persistent impairments in HRQOL. Conclusions: Adolescent SRC is associated with temporary impairments in HRQOL that resolve in patients followed until physician-documented clinical recovery. Compared to SRF, adolescent SRC patients experience significantly greater impairments in cognitive, school, and overall HRQOL. The degree of impairment experienced by adolescent SRC patients across HRQOL domains is impacted by initial symptom burden and length of clinical recovery. Future studies are needed to identify the clinico-pathological features associated with impaired HRQOL and assess whether the initiation of multi-disciplinary targeted rehabilitation strategies lead to an improvement in HRQOL in acute SRC patients.

Objectives: To summarize the clinical characteristics and outcomes of pediatric sports-related concussion (SRC) patients who were evaluated and managed at a multidisciplinary pediatric concussion program and examine the healthcare resources and personnel required to meet the needs of this patient population. Methods: We conducted a retrospective review of all pediatric SRC patients referred to the Pan Am Concussion Program from September 1st, 2013 to May 25th, 2015. Initial assessments and diagnoses were carried out by a single neurosurgeon. Return-to-Play decision-making was carried out by the multidisciplinary team. Results: 604 patients, including 423 pediatric SRC patients were evaluated at the Pan Am Concussion Program during the study period. The mean age of study patients was 14.30 years (SD: 2.32, range 7-19 years); 252 (59.57%) were males. Hockey (182; 43.03%) and soccer (60; 14.18%) were the most commonly played sports at the time of injury. Overall, 294 (69.50%) of SRC patients met the clinical criteria for concussion recovery, while 75 (17.73%) were lost to follow-up, and 53 (12.53%) remained in active treatment at the end of the study period. The median duration of symptoms among the 261 acute SRC patients with complete follow-up was 23 days (IQR: 15, 36). Overall, 25.30% of pediatric SRC patients underwent at least one diagnostic imaging test and 32.62% received referral to another member of our multidisciplinary clinical team. Conclusion: Comprehensive care of pediatric SRC patients requires access to appropriate diagnostic resources and the multidisciplinary collaboration of experts with national and provincially-recognized training in TBI.

OBJECTIVE There were 2 objectives of this study. The first objective was to identify clinical variables associated with vestibulo-ocular dysfunction (VOD) detected at initial consultation among pediatric patients with acute sports-related concussion (SRC) and postconcussion syndrome (PCS). The second objective was to reexamine the prevalence of VOD in this clinical cohort and evaluate the effect of VOD on length of recovery and the development of PCS. METHODS A retrospective review was conducted for all patients with acute SRC and PCS who were evaluated at a pediatric multidisciplinary concussion program from September 2013 to May 2015. Acute SRS was defined as presenting < 30 days postinjury, and PCS was defined according to the International Classification of Diseases, 10th Revision criteria and included being symptomatic 30 days or longer postinjury. The initial assessment included clinical history and physical examination performed by 1 neurosurgeon. Patients were assessed for VOD, defined as the presence of more than 1 subjective vestibular and oculomotor complaint (dizziness, diplopia, blurred vision, etc.) and more than 1 objective physical examination finding (abnormal near point of convergence, smooth pursuits, saccades, or vestibulo-ocular reflex testing). Poisson regression analysis was used to identify factors that increased the risk of VOD at initial presentation and the development of PCS. RESULTS Three hundred ninety-nine children, including 306 patients with acute SRC and 93 with PCS, were included. Of these patients, 30.1% of those with acute SRC (65.0% male, mean age 13.9 years) and 43.0% of those with PCS (41.9% male, mean age 15.4 years) met the criteria for VOD at initial consultation. Independent predictors of VOD at initial consultation included female sex, preinjury history of depression, posttraumatic amnesia, and presence of dizziness, blurred vision, or difficulty focusing at the time of injury. Independent predictors of PCS among patients with acute SRC included the presence of VOD at initial consultation, preinjury history of depression, and posttraumatic amnesia at the time of injury. CONCLUSIONS This study identified important potential risk factors for the development of VOD following pediatric SRC. These results provide confirmatory evidence that VOD at initial consultation is associated with prolonged recovery and is an independent predictor for the development of PCS. Future studies examining clinical prediction rules in pediatric concussion should include VOD. Additional research is needed to elucidate the natural history of VOD following SRC and establish evidence-based indications for targeted vestibular rehabilitation.

Background Numerous medications are available for the acute treatment of migraine in adults, and some have now been approved for use in children and adolescents in the ambulatory setting. A systematic review of acute treatment of migraine medication trials in children and adolescents will help clinicians make evidence-informed management choices. Objectives To assess the effects of pharmacological interventions by any route of administration versus placebo for migraine in children and adolescents 17 years of age or less. For the purposes of this review, children were defined as under 12 years of age and adolescents 12 to 17 years of age. Search methods We searched seven bibliographic databases and four clinical trial registers as well as gray literature for studies through February 2016. Selection criteria We included prospective randomized controlled clinical trials of children and adolescents with migraine, comparing acute symptom relieving migraine medications with placebo in the ambulatory setting. Data collection and analysis Two reviewers screened titles and abstracts and reviewed the full text of potentially eligible studies. Two independent reviewers extracted data for studies meeting inclusion criteria. We calculated the risk ratios (RRs) and number needed to treat for an additional beneficial outcome (NNTB) for dichotomous data. We calculated the risk difference (RD) and number needed to treat for an additional harmful outcome (NNTH) for proportions of adverse events. The percentage of pain-free patients at two hours was the primary efficacy outcome measure. We used adverse events to evaluate safety and tolerability. Secondary outcome measures included headache relief, use of rescue medication, headache recurrence, presence of nausea, and presence of vomiting. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created 'Summary of findings' tables. Main results We identified a total of 27 randomized controlled trials (RCTs) of migraine symptom-relieving medications, in which 9158 children and adolescents were enrolled and 7630 (range of mean age between 8.2 and 14.7 years) received medication. Twenty-four studies focused on drugs in the triptan class, including almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, sumatriptan + naproxen sodium, and zolmitriptan. Other medications studied included paracetamol (acetaminophen), ibuprofen, and dihydroergotamine (DHE). More than half of the studies evaluated sumatriptan. All but one study reported adverse event data. Most studies presented a low or unclear risk of bias, and the overall quality of evidence, according to GRADE criteria, was low to moderate, downgraded mostly due to imprecision and inconsistency. Ibuprofen was more effective than placebo for producing pain freedom at two hours in two small studies that included 162 children (RR 1.87, 95% confidence interval (CI) 1.15 to 3.04) with low quality evidence (due to imprecision). Paracetamol was not superior to placebo in one small study of 80 children. Triptans as a class of medication were superior to placebo in producing pain freedom in 3 studies involving 273 children (RR 1.67, 95% CI 1.06 to 2.62, NNTB 13) (moderate quality evidence) and 21 studies involving 7026 adolescents (RR 1.32, 95% CI 1.19 to 1.47, NNTB 6) (moderate quality evidence). There was no significant difference in the effect sizes between studies involving children versus adolescents. Triptans were associated with an increased risk of minor (non-serious) adverse events in adolescents (RD 0.13, 95% CI 0.08 to 0.18, NNTH 8), but studies did not report any serious adverse events. The risk of minor adverse events was not significant in children (RD 0.06, 95% CI − 0.04 to 0.17, NNTH 17). Sumatriptan plus naproxen sodium was superior to placebo in one study involving 490 adolescents (RR 3.25, 95% CI 1.78 to 5.94, NNTB 6) (moderate quality evidence). Oral dihydroergotamine was not superior to placebo in one small study involving 13 children. Authors' conclusions Low quality evidence from two small trials shows that ibuprofen appears to improve pain freedom for the acute treatment of children with migraine. We have only limited information on adverse events associated with ibuprofen in the trials included in this review. Triptans as a class are also effective at providing pain freedom in children and adolescents but are associated with higher rates of minor adverse events. Sumatriptan plus naproxen sodium is also effective in treating adolescents with migraine.

Background Many concussion symptoms, such as headaches, vision problems, or difficulty remembering or concentrating may deleteriously affect school functioning. Our objective was to determine if academic performance was lower in the academic calendar year that students sustain a concussion compared to the previous year when they did not sustain a concussion. Methods Using Manitoba Health and Manitoba Education data, we conducted a population-based, controlled before-after study from 2005-2006 to 2010-2011 academic years. Grade 9-12 students with an ICD9/10 code for concussion were matched to non-concussed controls. Overall changes in grade point average (GPA) were compared for the academic year prior to the concussion to the academic year the concussion occurred (or could have occurred among non-concussed matched students). Results Overall, 8240 students (1709 concussed, 6531 non-concussed students) were included. Both concussed and non-concussed students exhibited a lower overall GPA from one year to the next. Having sustained a concussion resulted in a -0.90% (95% CI: -1.88, 0.08) reduction in GPA. Over the same period, non-concussed matched students' GPA reduced by -0.57% (95% CI: -1.32, 0.19). Students who sustained a concussion during high school were just as likely to graduate within four years as their non-concussed peers (ORadj: 0.84; 95% CI: 0.73, 1.02). Conclusions We found that, at a population level, a concussion had minimal long-term effects on academic performance during high school. While academic accommodations and Return-to-Learn programs are an important component of pediatric concussion management, research is needed to identify risk factors for poor academic performance after a concussion and who should receive these programs.

Background Croup is a common childhood illness characterized by barky cough, stridor, hoarseness and respiratory distress. Children with severe croup are at risk for intubation. Nebulized epinephrine (NE) may prevent intubation. Objectives To evaluate the efficacy and safety of NE in children presenting to emergency department (ED) or admitted to hospital with croup. Search methods We searched CENTRAL (The Cochrane Library 2010, Issue 4), containing the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (1966 to November Week 1, 2010), EMBASE (1980 to November 2010), Web of Science (1974 to November 2010), CINAHL (1982 to November 2010) and Scopus (1996 to November 2010). Selection criteria Randomized controlled trials (RCTs) or quasi-RCTs of children with croup evaluated in an ED or admitted to hospital. Comparisons were: NE versus placebo, racemic NE versus L-epinephrine (an isomer), and NE delivered by intermittent positive pressure breathing (IPPB) versus NE without IPPB. Primary outcome was change in croup score post-treatment. Secondary outcomes were rate and duration of intubation and hospitalization, croup return visit, parental anxiety and side effects. Data collection and analysis Two authors independently identified potentially relevant studies by title and abstract (when available) and examined relevant studies using a priori inclusion criteria, followed by methodologic quality assessment. One author extracted data while the second checked accuracy. We performed standard statistical analyses. Main results Eight studies (225 participants) were included. NE was associated with croup score improvement 30 minutes post-treatment (three RCTs, standardized mean difference (SMD) -0.94; 95% confidence interval (CI) -1.37 to -0.51; I2 statistic = 0%). This effect was not significant two and six hours post-treatment. NE was associated with significantly shorter hospital stay than placebo (one RCT, mean difference -32.0 hours; 95% CI -59.1 to -4.9). Comparing racemic and L-epinephrine, no difference in croup score was found after 30 minutes (SMD 0.33; 95% CI -0.42 to 1.08). After two hours, L-epinephrine showed significant reduction compared with racemic epinephrine (one RCT, SMD 0.87; 95% CI 0.09 to 1.65). There was no significant difference in croup score between administration of NE via IPPB versus nebulization alone at 30 minutes (one RCT, SMD -0.14; 95% CI -1.24 to 0.95) or two hours (SMD -0.72; 95% CI -1.86 to 0.42). Authors' conclusions NE is associated with clinically and statistically significant transient reduction of symptoms of croup 30 minutes post-treatment. Evidence does not favor racemic epinephrine or LE, or IPPB over simple nebulization. Plain Language Summary Nebulized epinephrine for croup in children Croup is a common childhood illness that is usually caused by a viral infection. Symptoms of croup include a hoarse voice, a 'barking' cough and noisy breathing. These symptoms are the result of swelling that occurs in the area of the windpipe (trachea) just below the voice box (larynx). Although most cases of croup are mild and resolve on their own, occasionally the swelling can be severe enough to cause difficulty in breathing. In these children, epinephrine (also called adrenaline) is a medication that is inhaled as a mist to temporarily shrink the swollen area in the trachea. This review looked at trials of inhaled epinephrine for the treatment of children with croup. Compared to no medication, inhaled epinephrine improved croup symptoms in children at 30 minutes following treatment (three studies, 94 children). This treatment effect disappeared two hours after treatment (one study, 20 children). However, children's symptoms did not become worse than prior to treatment. No study measured adverse events. This review is comprised of only eight studies and the number of included children was small (225). Few studies examined similar outcomes, therefore data could often not be pooled and conclusions are based on one or few studies.

Background Bicycle-related head injuries are a common reason for paediatric emergency department visits. Helmets have been designed to reduce head injuries, and helmet use has been encouraged through mandatory helmet legislation and nonlegislation helmet promotion activities. Objectives To synthesize the evidence published in the Cochrane Database of Systematic Reviews regarding bicycle helmet use among children, including helmet effectiveness and methods to promote helmet use. Methods The Cochrane Database of Systematic Reviews was searched for all systematic reviews where ‘bicycle*’ or ‘helmet’ appeared in title, abstract or keywords. Reviews were included if they examined paediatric data concerning head injuries among helmeted and nonhelmeted cyclists, helmet use or adverse consequences of helmets. Data pertaining to adults were excluded. Relevant data were extracted, entered into tables and synthesized using qualitative and quantitative methods. Main results Three systematic reviews were identified and included 21 observational studies and 14 experimental studies. The methodological quality was assessed in only two of the reviews: the quality was similar in studies examining legislative interventions and several weaknesses were identified in the nonlegislative interventions. Among children, helmet use resulted in a 63% reduction in medically reported head injuries [adjusted odds ratio (OR): 0.37; 95% confidence interval (CI): 0.20, 0.66] and an 86% reduction in the odds of brain injuries (OR: 0.14; 95% CI: 0.05, 0.38). Enactment of mandatory helmet legislation for child cyclists reduced the odds of head injury hospitalizations by 45%, while the odds of head injury hospitalizations reduced by 27% among children in jurisdictions without legislation. There was a significant reduction in traumatic brain injury among children cycling after the passage of helmet legislation (OR: 0.82; 95% CI: 0.76, 0.89); however, there was no significant decrease in other head and facial injuries post-legislation (OR: 1.08; 95% CI: 0.90, 1.23). Legislation also resulted in a significant increase in the number of children observed wearing a helmet (prevalence ratio: 3.69; 95% CI: 2.65, 5.14). Compared with children who received no intervention, those who received nonlegislative helmet promotion activities had a significant increase in observed helmet wearing (OR: 2.08; 95% CI: 1.29, 3.34), self-reported helmet wearing (OR: 3.27; 95% CI: 1.56, 6.87) and self-reported helmet ownership (OR: 2.67; 95% CI: 0.89, 8.03). No adverse events were associated with helmet use among cyclists. Authors' conclusions Bicycle helmets appear to be an effective way to reduce head injuries among children. Interventions to increase helmet use may be effective, particularly community-based, school-based, and those that provide free helmets; however, no effect of the interventions on helmet use were reported in randomized controlled trials. Finally, helmet legislation appears to be effective in increasing helmet use and reducing head injuries. Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. The Cochrane Collaboration

Background Anxiety disorders are among the most common psychiatric disorders diagnosed during childhood and adolescence. Reported lifetime prevalence of children or adolescents meeting criteria for at least one anxiety disorder in industrialized countries ranges from 8–27%. Current treatment includes psychotherapy (cognitive and behavioural therapies) as well as medication which is almost always used together with psychotherapy, rather than as a stand-alone treatment. Objective To synthesize the evidence currently in the Cochrane Database of Systematic Reviews (CDSR) related to the question: ‘In the treatment of childhood and adolescent anxiety disorders, which pharmacologic or nonpharmacologic treatments are known to improve symptom response, response rates, functional capacity, adherence, persistence, and acceptability as well as increase diagnostic remission and decrease adverse events?’. Methods The CDSR was searched using the term ‘anxiety disorders’ in the title for all systematic reviews examining pharmacologic and nonpharmacologic interventions for the treatment of anxiety disorders in children and adolescents, including pharmacotherapy and psychotherapy. Data were extracted and entered into tables; data were synthesized using qualitative and quantitative methods. Main Results Of the studies included in the CDSR, treatment of childhood and adolescent anxiety disorders with cognitive behavioural therapy (CBT) led to significant reductions in anxiety symptoms and increased recovery. Treatment with CBT or behavioural therapy (BT) led to notable reductions in Obsessive–Compulsive Disorder (OCD) severity and a reduced risk of treatment failure. Use of selective serotonin reuptake inhibitors (SSRIs) and the selective norepinephrine reuptake inhibitor (SNRI) venlafaxine were superior to placebo in treating OCD and other anxiety disorders. There was no clear evidence that any particular SSRI or venlafaxine was most efficacious or best tolerated. While few studies were available, CBT combined with a SSRI or SNRI led to significant reductions in both anxiety and OCD symptoms. Psychotherapy (CBT/BT), used alone or in combination with medication, had a mixed impact on reducing risk of treatment failure for OCD. Author's Conclusions For childhood and adolescent anxiety disorders, including OCD, the CDSR reviews suggest that psychotherapy treatments are efficacious in reducing symptom severity. Although the CDSR does not include a number of recent research publications on CBT, these newer studies further reinforce CBT efficacy. Pharmacotherapy evidence from the CDSR supports using medication in treating anxiety disorders, and while few studies examined combined pharmacological and psychological treatment, results to date are also favourable for this combination. Clinicians should rely on expert consensus guidelines vis-a-vis this evidence as treatment decision-making should be moderated by the patient's illness severity. Psychotherapy remains the first line treatment for mild to moderate symptoms, whereas pharmacotherapy is used for severe or treatment-resistant disorders. In conclusion, there is a body of literature in the CDSR to support evidence-based treatment decisions for pediatric anxiety disorders; however, as this is a field that is rapidly expanding its knowledge base, efforts must be made to ensure the most recent evidence is consistently incorporated. Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Background Globally, pneumonia is the leading cause of death among children and also results in significant morbidity. The most common treatment options include anti-pyretics and antibiotics. Other treatments include vitamins and over-the-counter cough syrup. Objective This overview presents a summary of the results of previous Cochrane reviews on the treatment of community acquired pneumonia (CAP) in children. Methods The Cochrane Database of Systematic Reviews was searched for all systematic reviews examining the treatment of pediatric pneumonia or lower respiratory tract infections. All reviews that were under the heading “pneumonia” on the Cochrane Acute Respiratory Infections (ARI) Group's Topic List and the ARI group were consulted. Data were extracted and entered into tables; data were synthesized using qualitative and quantitative methods. Main Results Eight reviews and one protocol were identified and data were available from seven reviews. Azithromycin and amoxicillin-clavulanate appeared to be equivalent for CAP in developed countries. In comparing beta-lactams, one small low-quality trial showed a higher cure rate with amoxicillin-clavulanate than with amoxicillin. In comparing macrolides, the efficacy of azithromycin, clarithromycin, and erythromycin appeared to be equal. Azithromycin was better tolerated than was amoxicillin-clavulanate. For CAP in developing countries, the failure rate was lower for amoxicillin than for co-trimoxazole. Initial therapy with oral or parenteral antibiotics were equivalent in children with non-severe pneumonia. A 3-day course of amoxicillin or of co-trimoxazole had an equivalent clinical cure rate, treatment failure rate and relapse rate when compared to a 5-day course. Inconsistent outcomes were shown in studies of vitamin A for therapy of non-measles pneumonia. There were insufficient children in the studies of over-the-counter medications for cough in children with pneumonia to reach meaningful conclusions. Conclusions Although thousands of children have been enrolled in trials of CAP treatments, limited conclusions can be reached about the ideal treatment, route and duration in developed or developing countries and for children of various ages. The primary reason for this is the multitude of interventions studied in diverse populations. Another major problem is that the diagnosis of pneumonia was often clinical rather than radiographic—often by necessity in developing countries. Even when pneumonia was diagnosed radiographically, differentiating viral from bacterial pneumonia was often not practical. Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. The Cochrane Collaboration

Background Asthma is characterized by chronic airway inflammation and affects many children. One treatment option used to control asthma symptoms is the class of medications known as the long acting β2-agonists (LABA) and they are often used in combination with inhaled corticosteroids (ICS). The use of LABA in children has been widely debated in the literature. Objectives To synthesize the evidence currently in the Cochrane Library of systematic reviews related to the question: ‘In children with symptomatic asthma, does treatment with a LABA as a primary or add-on therapy to ICS improve objective measures of lung function and asthma symptom control, reduce exacerbations, and improve quality of life?’. Methods The Cochrane Database of Systematic Reviews was searched using the term ‘asthma’ in the title for all systematic reviews examining LABA vs any other pharmacological agent for the treatment of asthma. Data were extracted and entered into tables; syntheses occurred using qualitative and quantitative methods. Main Results Seven reviews were identified; however, only four reviews contained data for children. There was no significant difference in the asthma exacerbations among those treated with LABA or any other treatment. For those treated with LABA with no/varied ICS vs placebo with no/varied ICS, there was a significant improvement in percent predicted forced expiratory volume in the first second (FEV1) and a significant number of children had a ≥ 15% increase in FEV1. There was also a significant reduction in the change in whole day rescue medication, fewer asthma related night-time wakenings, and lower symptom scores for LABA with no/varied ICS. Change in FEV1 (Litres (L) or percent predicted) and improvement in morning and evening peak expiratory flow (PEF) favoured LABA and ICS vs fixed dose ICS and placebo. There was a significantly higher risk of adverse events among those receiving LABA and ICS compared to ICS with or without placebo. Authors' Conclusions There is no clear benefit to LABA in preventing asthma exacerbations in children. While there is a paucity of evidence in this area, ICS should remain the controller therapy of choice; however, the addition of LABA to ICS may result in improvement in pulmonary function measures, reduce the use of rescue medications and improve quality of life measures in children with chronic asthma. Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. The Cochrane Collaboration

Background Asthma is a common childhood disease characterised by chronic inflammation of the airways. One treatment option is the class of medications known as the leukotriene receptor antagonists (LTRAs). The use of LTRA in combination with inhaled corticosteroid (ICS) may improve asthma control by reducing mucus secretion, inflammation and bronchoconstriction via this alternate pathway. Objectives To synthesise the evidence currently in The Cochrane Library Database Of Systematic Reviews (CDSR) related to the question, ‘In children with symptomatic but stable asthma, does treatment with a LTRA as a primary or add-on therapy to ICS improve objective measures of lung function and asthma symptom control, reduce exacerbations, and improve quality of life compared to standard care?’ Methods CDSR was searched using the term ‘asthma’ in the title for all systematic reviews examining anti-leukotriene agents vs any other pharmacological agent for the treatment of asthma. Data were extracted and entered into tables; data were synthesised using qualitative and quantitative methods. Main Results Three reviews were identified; however, only two reviews contained data in children. There was no significant difference in change in FEV1, number of missed school days, or the proportion of children requiring oral corticosteroid treatment, or proportion of children who experienced an asthma exacerbation requiring hospital admission among those randomised to LTRA vs ICS. The addition of LTRA treatment to ICS resulted in no significant difference in the change in FEV1 or morning PEFR, use of β2-agonist rescue medication, proportion of children admitted to the hospital due to an asthma exacerbation, or quality of life. Authors' Conclusions Until further evidence is available for children, LTRAs should not be substituted for ICS as monotherapy and ICS should remain the first line therapy for children with asthma. Currently, there is insufficient evidence to conclude that anti-leukotriene agents added to ICS therapy improves asthma control, steroid-sparing effect, or improved quality of life. Future research should address the gaps in children, including those as young as 2 years of age. Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. The Cochrane Collaboration

Background: This study systematically reviews literature regarding the diagnosis of occupational asthma (OA) and compares specific inhalation challenge (SIC) testing with alternative tests. Methods: Electronic databases and trials registries were searched; additional references were identified from bibliographic searches of included studies, hand searches of conferences, and author contacts. Various study designs (clinical trials, cohorts, cross-sectional, or case series) were included involving workers with suspected OA. All diagnostic tests were compared to a “reference standard,” and two researchers independently extracted 2 × 2 data. Pooled sensitivities and specificities (95% confidence intervals [CIs]) were derived. Results: Seventy-seven studies were included. For high molecular weight (HMW) agents, the nonspecific bronchial provocation (NSBP) test, skin-prick test (SPT), and serum-specific IgE had sensitivities > 73% when compared to SIC. Specificity was highest for specific IgE vs SIC (79.0%; 95% CI, 50.5 to 93.3%). The highest sensitivity among low molecular weight asthmagens occurred between combined NSBP and SPT vs SIC (100%; 95% CI, 74.1 to 100%). When compared to SIC, specific IgE and SPT had similar specificities (88.9%; 95% CI, 84.7 to 92.1%; and 86.2%; 95% CI, 77.4 to 91.9%, respectively). For HMW agents, high specificity was demonstrated for positive NSBP tests and SPTs alone (82.5%; 95% CI, 54.0 to 95.0%) or when combined with specific IgE (74.3%; 95% CI, 45.0 to 91.0%) vs SIC. Sensitivity was somewhat lower (60.6% and 65.2%, respectively). Conclusions: In appropriate clinical situations when SIC is not available, the combination of a NSBP test with a specific SPT or specific IgE may be an appropriate alternative to SIC in diagnosing OA. While positive results of single NSBP test, specific SPT, or serum-specific IgE testing would increase the likelihood of OA, a negative result could not exclude OA.

Background Dehydration associated with gastroenteritis is a serious complication. Oral rehydration is an effective and inexpensive treatment, but some physicians prefer intravenous methods. Objectives To compare oral with intravenous therapy for treating dehydration due to acute gastroenteritis in children. Search strategy We searched the Cochrane Infectious Diseases Group Specialized Register (March 2006), CENTRAL (The Cochrane Library 2006, Issue 1), MEDLINE (1966 to March 2006), EMBASE (1974 to March 2006), LILACS (1982 to March 2006), and reference lists. We also contacted researchers, pharmaceutical companies, and relevant organizations. Selection criteria Randomized and quasi-randomized controlled trials comparing intravenous rehydration therapy (IVT) with oral rehydration therapy (ORT) in children up to 18 years of age with acute gastroenteritis. Data collection and analysis Two authors independently extracted data and assessed quality using the Jadad score. We expressed dichotomous data as a risk difference (RD) and number needed to treat (NNT), and continuous data as a weighted mean difference (WMD). We used meta-regression for subgroup analyses. Main results Seventeen trials (1811 participants), of poor to moderate quality, were included. There were more treatment failures with ORT (RD 4%, 95% confidence interval (CI) 1 to 7, random-effects model; 1811 participants, 18 trials; NNT = 25). Six deaths occurred in the IVT group and two in the ORT groups (4 trials). There were no significant differences in weight gain (369 participants, 6 trials), hyponatremia (248 participants, 2 trials) or hypernatremia (1062 participants, 10 trials), duration of diarrhea (960 participants, 8 trials), or total fluid intake at six hours (985 participants, 8 trials) and 24 hours (835 participants, 7 trials). Shorter hospital stays were reported for the ORT group (WMD -1.20 days, 95% CI -2.38 to -0.02 days; 526 participants, 6 trials). Phlebitis occurred more often in the IVT group (NNT 50, 95% CI 25 to 100) and paralytic ileus more often in the ORT group (NNT 33, 95% CI 20 to 100, fixed-effect model), but there was no significant difference between ORT using the low osmolarity solutions recommended by the World Health Organization and IVT (729 participants, 6 trials). Authors' conclusions Although no clinically important differences between ORT and IVT, the ORT group did have a higher risk of paralytic ileus, and the IVT group was exposed to risks of intravenous therapy. For every 25 children (95% CI 14 to 100) treated with ORT one would fail and require IVT. Plain language summary Children with dehydration due to gastroenteritis need to be rehydrated, and this review did not show any important differences between giving fluids orally or intravenously Dehydration is when body water content is reduced causing dry skin, headaches, sunken eyes, dizziness, confusion, and sometimes death. Children with dehydration due to gastroenteritis need rehydrating either by liquids given by mouth or a tube through the nose, or intravenously. The review of 17 trials (some funded by drug companies) found that the trials were not of high quality; however the evidence suggested that there are no clinically important differences between giving fluids orally or intravenously. For every 25 children treated with fluids given orally, one child would fail and require intravenous rehydration. Further, the results for low osmolarity solutions, the currently recommended treatment by the World Health Organization, showed a lower failure rate for oral rehydration that was not significantly different from that of intravenous rehydration. Oral rehydration should be the first line of treatment in children with mild to moderate dehydration with intravenous therapy being used if the oral route fails. The evidence showed that there may be a higher risk of paralytic ileus with oral rehydration while intravenous therapy carries the risk of phlebitis (ie inflammation of the veins).

OBJECT The objectives of this study were twofold: 1) to examine the prevalence of emotional symptoms among children and adolescents with a sports-related concussion (SRC) who were referred to a multidisciplinary pediatric concussion program and 2) to examine the prevalence, clinical features, risk factors, and management of postinjury psychiatric outcomes among those in this clinical population. METHODS The authors conducted a retrospective chart review of all patients with SRC referred to a multidisciplinary pediatric concussion program between September 2013 and October 2014. Clinical assessments carried out by a single neurosurgeon included clinical history, physical examination, and Post-Concussion Symptom Scale (PCSS) scoring. Postinjury psychiatric outcomes were defined as a subjective worsening of symptoms of a preinjury psychiatric disorder or new and isolated suicidal ideation or diagnosis of a novel psychiatric disorder (NPD). An NPD was defined as a newly diagnosed psychiatric disorder that occurred in a patient with or without a lifetime preinjury psychiatric disorder after a concussion. Clinical resources, therapeutic interventions, and clinical and return-to-play outcomes are summarized. RESULTS One hundred seventy-four patients (mean age 14.2 years, 61.5% male) were included in the study. At least 1 emotional symptom was reported in 49.4% of the patients, and the median emotional PCSS subscore was 4 (interquartile range 1–8) among those who reported at least 1 emotional symptom. Overall, 20 (11.5%) of the patients met the study criteria for a postinjury psychiatric outcome, including 14 patients with an NPD, 2 patients with isolated suicidal ideation, and 4 patients with worsening symptoms of a preinjury psychiatric disorder. Female sex, a higher initial PCSS score, a higher emotional PCSS subscore, presence of a preinjury psychiatric history, and presence of a family history of psychiatric illness were significantly associated with postinjury psychiatric outcomes. Interventions for patients with postinjury psychiatric outcomes included pharmacological therapy alone in 2 patients (10%), cognitive behavioral therapy alone in 4 (20%), multimodal therapy in 9 (45%), and no treatment in 5 (25%). Overall, 5 (25%) of the patients with postinjury psychiatric disorders were medically cleared to return to full sports participation, whereas 5 (25%) were lost to follow-up and 9 (45%) remained in treatment by the multidisciplinary concussion program at the end of the study period. One patient who was asymptomatic at the time of initial consultation committed suicide. CONCLUSIONS Emotional symptoms were commonly reported among pediatric patients with SRC referred to a multidisciplinary pediatric concussion program. In some cases, these symptoms contributed to the development of an NPD, isolated suicidal ideation, and worsening symptoms of a preexisting psychiatric disorder. Future research is needed to clarify the prevalence, pathophysiology, risk factors, and evidence-based management of postinjury psychiatric outcomes after pediatric SRC. Successful management of these patients requires prompt recognition and multidisciplinary care by experts with clinical training and experience in concussion and psychiatry.

OBJECTIVE: To evaluate the awareness of concussion-related symptoms amongst members of the sports community in Canada. METHODS: A cross-sectional national electronic survey was conducted. Youth athletes, parents, coaches and medical professionals across Canada were recruited through mailing lists from sports-related opt-in marketing databases. Participants were asked to identify, from a list of options, the symptoms of a concussion. The proportion of identified symptoms (categorized as physical, cognitive, mental health-related and overall) as well as participant factors associated with symptom recognition were analyzed. RESULTS: The survey elicited 6,937 responses. Most of the respondents (92.1%) completed the English language survey, were male (57.7%), 35-54 years of age (61.7%), with post-secondary education (58.2%), or high reported yearly household income (>$80,000; 53.0%). There were respondents from all provinces and territories with the majority of respondents from Ontario (35.2%) or British Columbia (19.1%). While participants identified most of the physical (mean = 84.2% of symptoms) and cognitive (mean = 91.2% of symptoms), they on average only identified 53.5% of the mental health-related symptoms of concussions. Respondents who were older, with higher education and household income, or resided in the Northwest Territories or Alberta identified significantly more of the mental health-related symptoms listed. INTERPRETATION: While Canadian youth athletes, parents, coaches and medical professionals are able to identify most of the physical and cognitive symptoms associated with concussion, identification of mental health-related symptoms of concussion is still lagging. Language: en

Aim: To examine the online personnel and practice profiles of concussion healthcare providers in the USA. Methods: We conducted independent, blinded, Google Internet searches for concussion healthcare providers using the terms ‘concussion clinic’ and ‘concussion program’ and each American state and completed a critical appraisal of healthcare personnel and services at these websites. Results: A total of 184 concussion healthcare providers were identified. Despite offering care to traumatic brain injury (TBI) patients, access to professionals with expertise in TBI including neuropsychologists (40.8%), neurologists (33.7%) and neurosurgeons (21.7%) was variable across sites. Conclusion: Concussion healthcare in the USA is presently delivered by a range of healthcare professionals with varying levels of training in TBI offering a variety of services.

Objective Determine longitudinal changes in health-related quality of life (HRQoL) in youth during recovery from a sport-related concussion. Design Prospective case-series. Participants 68 youth (13–18 years; 62% male) with an acute sport-related concussion were enrolled with 5 lost to follow-up. Intervention (or assessment of risk factors) Subsequently developing Post-Concussion Syndrome (PCS: symptomatic after 30 days), initial symptom severity (Post Concussion Symptom Scale), concussion history, sex, age, and academic accommodations during recovery. Outcome measures PedsQL Cognitive Functioning Scale and PedsQL 4.0 measured physical, social, and emotional domains of HRQoL. They were administered before each appointment until medical clearance. Multivariable mixed modelling accounted for repeated measures within an athlete and expressed as point increase per week. Main results Initial mean HRQoL was highest for social (non-PCS: 92.7 out of 100; PCS: 86.3), followed by emotional (non-PCS: 86.45; PCS: 69.7), physical (non-PCS: 80.95; PCS: 49.2), and cognitive domains (non-PCS: 69.1; PCS: 50.3). There was effect modification by developing PCS. Changes in HRQoL subscores were: cognitive functioning non-PCS (+9.8 points [95% CI: 6.9, 12.7]) and PCS (+4.2 points [95% CI: 2.8, 5.6]); social HRQoL non-PCS (+2.3 points [1.0, 4.0]) and PCS (+0.5 points [0.1, 1.0); emotional HRQoL non-PCS (+5.0 points [95% CI: 2.9, 7.0]) and PCS points (+2.2 [1.6, 2.9]); and physical non-PCS (+6.3 points [95% CI: [3.5, 9.2]) and PCS (+3.3 points (95% CI: 2.5, 4.2). Conclusions HRQoL significantly improved longitudinally with greater improvement among non-PCS athletes. HRQoL impairment was most apparent in the cognitive and physical domains. Competing interests None.

Objective Determine change in report card grades in youth after sustaining an acute sport-related concussion. Design Prospective case-series. Setting Paediatric, multi-disciplinary concussion. Participants 48 youth athletes (mean age 14.3; SD: 0.9; male: 57.6%) who sustained a sport-related concussion during the school year. Overall, 3 youth were lost to follow-up and 12 youth submitted only one report card. Interventions (or assessment of risk factors) Subsequently developing Post-Concussion Syndrome (PCS: symptomatic after 30 days), initial concussion severity (Post Concussion Symptom Scale), self-reported concussion history, sex, age, and academic accommodations during recovery. Outcome measures The report card immediately before the concussion and the report card immediately after medical clearance were collected. Pre-concussion and post-concussion overall and core grade-point average was calculated from report cards. Core grade-point average (GPA) included math, sciences, social studies, English, and foreign languages. Main results Overall GPA was 82.9% (SD 8.5%) pre-concussion and 82.7% (SD 8.0%) after concussion recovery (difference: −0.2%, 95% CI: −1.6%, 1.1%). Core GPA was 80.0% (SD 10.1%) pre-concussion and 79.4% (SD 10.4%) after concussion recovery (difference: −0.6%, 95% CI: −2.8%, 1.6%). There were no significant differences in overall or core GPA when stratified by sex, age, initial concussion severity, previous concussion history, receiving adequate school accommodations during recovery, or subsequently developing PCS. Conclusions There were no statistically or clinically significant changes in overall or core GPA during concussion recovery. Further research is needed to determine if there are more subtle changes in academic performance during the recovery process. Competing interests None.

Objective Determine if youth athletes with a history of concussion had more symptoms, higher symptom score, longer recovery, or were more likely to be diagnosed with Post-Concussion Syndrome (PCS) than those with no history of concussion. Design Retrospective chart review. Setting Paediatric, multi-disciplinary concussion. Participants 306 youth (mean 14.0 years, SD 2.3; 65.5% male) with an acute sport-related concussion. Intervention (or assessment of risk factors) Self-reported concussion history. Outcome measures Recovery days were days between concussion and medical clearance by the neurosurgeon. Medical clearance occurred after tolerating full-time school, completing return-to-play protocol, and absence of vestibulo-ocular dysfunction. Initial symptoms were reported on the Post Concussion Symptom Severity score (PCSS); symptom severity was the total PCSS score. The neurosurgeon diagnosed Post-Concussion Syndrome (PCS) using ICD-10 criteria of symptoms for at least 30 days. Main results Median number of initial symptoms was 5.5 (IQR: 1–10) for youth with no concussion history and 7.0 (IQR: 2–14) with a concussion history (p=0.04). Initial median PCSS score was 9 (IQR: 1–22) for youth with no concussion history and 13 (IQR: 3–34) with a concussion history (p=0.03). Median recovery days was 22 (IQR: 15–43) for those with no concussion history compared to 23 (IQR: 16–39) with a concussion history (p=0.41). There was no significant difference in subsequently being diagnosed with PCS (no concussion history: 40.1%, ?concussion history: 41.7%, p=0.73). Conclusions Despite a significantly higher initial symptom burden among those with a concussion history, there was no increased risk of protracted recovery or subsequent diagnosis of PCS. Competing interests None.

Objective Summarise clinical characteristics, outcomes, and healthcare resources and personnel needs of paediatric sports-related concussion (SRC) patients who were evaluated and managed at a multi-disciplinary paediatric concussion program. Design Retrospective cohort study Setting Paediatric, multi-disciplinary concussion clinic Participants 423 paediatric SRC patients: 14.3 years (SD: 2.3), 59.6% males, 43.0% hockey-related, and 75.8% acute SRC Interventions (or assessment of risk factors) Initial assessment and diagnosis by a neurosurgeon with the multi-disciplinary team completing Return-to-Play decision-making. On-site neurosurgeon, neuropsychologist, vestibulo-ocular therapist, and exercise physiologist and referrals to neurology and psychiatry Outcome measures SRC diagnosis and recovery were defined by the 2013 Zurich Consensus Guidelines. Post-Concussion Syndrome was diagnosed using ICD-10 criteria of at least 3 symptoms at 30 days or more. Outcomes included demographic and injury data, healthcare resources and personnel utilised, and recovery Main results Overall, 294 (69.5%) of SRC patients met the clinical criteria for recovery, 75 (17.7%) were lost to follow-up, 53 (12.5%) remained in treatment, and 1 died (0.2%). In acute patients, median time to initial consultation was 7 days (IQR: 5, 12). Median days to recovery among acute SRC patients with complete follow-up was 23 days (IQR: 15, 36) and 44.1% of acute SRC patients were diagnosed with PCS. 25.3% of SRC patients underwent at least one diagnostic imaging test and 32.6% received referral to another member of our multi-disciplinary clinical team. Conclusions Youth received comprehensive care with access to appropriate diagnostic resources and multi-disciplinary collaboration of experts with national and provincially-recognised training in TBI Competing interests None.

Background Croup is a common childhood illness characterized by barky cough, stridor, hoarseness and respiratory distress. Children with severe croup are at risk for intubation. Nebulized epinephrine may prevent intubation. Objectives To assess the efficacy (measured by croup scores, rate of intubation and health care utilization such as rate of hospitalization) and safety (frequency and severity of side effects) of nebulized epinephrine versus placebo in children with croup, evaluated in an emergency department (ED) or hospital setting. Search methods We searched CENTRAL 2013, Issue 6, MEDLINE (1966 to June week 3, 2013), EMBASE (1980 to July 2013), Web of Science (1974 to July 2013), CINAHL (1982 to July 2013) and Scopus (1996 to July 2013). Selection criteria Randomized controlled trials (RCTs) or quasi-RCTs of children with croup evaluated in an ED or admitted to hospital. Comparisons were: nebulized epinephrine versus placebo, racemic nebulized epinephrine versus L-epinephrine (an isomer) and nebulized epinephrine delivered by intermittent positive pressure breathing (IPPB) versus nebulized epinephrine without IPPB. Primary outcome was change in croup score post-treatment. Secondary outcomes were rate and duration of intubation and hospitalization, croup return visit, parental anxiety and side effects. Data collection and analysis Two authors independently identified potentially relevant studies by title and abstract (when available) and examined relevant studies using a priori inclusion criteria, followed by methodological quality assessment. One author extracted data while the second checked accuracy. We use the standard methodological procedures expected by the Cochrane Collaboration. Main results Eight studies (225 participants) were included. In general, children included in the studies were young (average age less than two years in the majority of included studies). Severity of croup was described as moderate to severe in all included studies. Six studies took place in the inpatient setting, one in the ED and one setting was not specified. Six of the eight studies were deemed to have a low risk of bias and the risk of bias was unclear in the remaining two studies. Nebulized epinephrine was associated with croup score improvement 30 minutes post-treatment (three RCTs, standardized mean difference (SMD) -0.94; 95% confidence interval (CI) -1.37 to -0.51; I2 statistic = 0%). This effect was not significant two and six hours post-treatment. Nebulized epinephrine was associated with significantly shorter hospital stay than placebo (one RCT, MD -32.0 hours; 95% CI -59.1 to -4.9). Comparing racemic and L-epinephrine, no difference in croup score was found after 30 minutes (SMD 0.33; 95% CI -0.42 to 1.08). After two hours, L-epinephrine showed significant reduction compared with racemic epinephrine (one RCT, SMD 0.87; 95% CI 0.09 to 1.65). There was no significant difference in croup score between administration of nebulized epinephrine via IPPB versus nebulization alone at 30 minutes (one RCT, SMD -0.14; 95% CI -1.24 to 0.95) or two hours (SMD -0.72; 95% CI -1.86 to 0.42). None of the studies sought or reported data on adverse effects. Authors' conclusions Nebulized epinephrine is associated with clinically and statistically significant transient reduction of symptoms of croup 30 minutes post-treatment. Evidence does not favor racemic epinephrine or L-epinephrine, or IPPB over simple nebulization. The authors note that data and analyses were limited by the small number of relevant studies and total number of participants and thus most outcomes contained data from very few or even single studies.

Background Since the initial publication of this systematic review in 1997, several randomized trials examining the benefit of glucocorticoids have been published. The objective of this review is to provide evidence to guide clinicians in their treatment of patients with croup by determining the effectiveness of glucocorticoids and to identify areas requiring future research. Objectives To determine the effect of glucocorticoids for children with croup. Search methods We searched CENTRAL (2010, Issue 3), which contains the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (1966 to July week 2, 2010) and EMBASE.com (1974 to July 2010). We also contacted authors of identified croup trials published in the last 10 years to inquire about additional published or unpublished trials. Selection criteria Randomized controlled trials (RCTs) that examine children with croup and objectively measure the effectiveness of glucocorticoids. Data collection and analysis Two review authors identified studies for potential relevance based on the review of the title and abstract (when available). Two review authors independently reviewed studies for relevance using a priori inclusion criteria and assessed trial quality. Differences were resolved by consensus. One review author extracted data using a structured form and another review author checked the results for accuracy. We performed standard statistical analyses. Main results Thirty-eight studies were included (n = 4299). Glucocorticoids were associated with an improved Westley score (maximum 17 points) at six hours with a mean difference of -1.2 (95% confidence interval (CI) -1.6 to -0.8) and at 12 hours -1.9 (95% CI -2.4 to -1.3); at 24 hours this improvement was no longer significant (-1.3, 95% CI -2.7 to 0.2). Fewer return visits and/or (re)admissions occurred in participants treated with glucocorticoids (risk ratio (RR) 0.5; 95% CI 0.3 to 0.7). Length of time spent in accident and emergency or hospital (mean difference 12 hours, five to 19 hours) was significantly decreased for participants treated with glucocorticoids. Use of epinephrine decreased for children treated with a glucocorticoid (risk difference 10%; 95% CI 1 to 20). Authors' conclusions Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and/or (re)admissions are required and the length of time spent in hospital is decreased. Research is required to examine the most beneficial method for disseminating croup practice guidelines and to increase the uptake of evidence.

Background Methamphetamine (MA) is a potent stimulant that is readily available. Its effects are similar to cocaine, but the drug has a profile associated with increased acute and chronic toxicities. The objective of this systematic review was to identify and synthesize literature on risk factors that are associated with MA use among youth. More than 40 electronic databases, websites, and key journals/meeting abstracts were searched. We included studies that compared children and adolescents (≤ 18 years) who used MA to those who did not. One reviewer extracted the data and a second checked for completeness and accuracy. For discrete risk factors, odds ratios (OR) were calculated and when appropriate, a pooled OR with 95% confidence intervals (95% CI) was calculated. For continuous risk factors, mean difference and 95% CI were calculated and when appropriate, a weighted mean difference (WMD) and 95% CI was calculated. Results were presented separately by comparison group: low-risk (no previous drug abuse) and high-risk children (reported previous drug abuse or were recruited from a juvenile detention center). Results Twelve studies were included. Among low-risk youth, factors associated with MA use were: history of heroin/opiate use (OR = 29.3; 95% CI: 9.8–87.8), family history of drug use (OR = 4.7; 95% CI: 2.8–7.9), risky sexual behavior (OR = 2.79; 95% CI: 2.25, 3.46) and some psychiatric disorders. History of alcohol use and smoking were also significantly associated with MA use. Among high-risk youth, factors associated with MA use were: family history of crime (OR = 2.0; 95% CI: 1.2–3.3), family history of drug use (OR = 4.7; 95% CI: 2.8–7.9), family history of alcohol abuse (OR = 3.2; 95% CI: 1.8–5.6), and psychiatric treatment (OR = 6.8; 95% CI: 3.6–12.9). Female sex was also significantly associated with MA use. Conclusion Among low-risk youth, a history of engaging in a variety of risky behaviors was significantly associated with MA use. A history of a psychiatric disorder was a risk factor for MA for both low- and high-risk youth. Family environment was also associated with MA use. Many of the included studies were cross-sectional making it difficult to assess causation. Future research should utilize prospective study designs so that temporal relationships between risk factors and MA use can be established.

No evidence-based Return-To-Learn program is available to help students return to school after a concussion. The objective was to examine the relationship between health-related quality of life (HRQoL), symptom severity, and school functioning in students with a sport-related concussion. This prospective case-series was conducted with students (13–18 years) who presented to the Pan Am Concussion Program in Winnipeg, Canada and were diagnosed with an acute sport-related concussion by a neurosurgeon. At each appointment, students completed the Post-concussion Symptom Severity (PCSS) scale, PedsQL 4.0 (physical, social, school, emotional functioning domains) and cognitive functioning. They received a log book to track school attendance. At medical clearance, exit interviews were conducted to examine the impact of their concussion on academics and HRQoL. Fifty-four students (57% male) were diagnosed with an acute-sport related concussion. Students initially presented with median PCSS score of 19 (IQR: 8, 34) and had poorest HRQoL in the physical and cognitive domains. At each medical appointment, PCSS score decreased by 6.3 points (95% CI: −7.6, −4.9). All HRQoL domains significantly improved over time; however, mean cognitive functioning scores remained the lowest at medical clearance (75.0; SD:3.8). There was no significant difference in median days to medical clearance among students who rated their school accommodations as poor (n = 8) compared with those who rated them as good (n = 20) (19 vs. 27 days; p = 0.42). Students missed a median of 7 days of school and returning to Math (16/27, 59%) and Science (14/29, 48%) was the most difficult. Concussion symptoms and all domains of HRQoL improve over time. Yet cognitive functioning scores (attention, remembering, and thinking) remain low after medical clearance and this could affect academic performance. This study provides evidence documenting students’ struggles when recovering from their concussion and returning to school. This information can help form a Return-To-Learn program.

Statement of purpose Post-concussion syndrome (PCS) refers to symptoms that last more than one month after a concussion, which increases the risk for anxiety, depression and poor academic performance. Our objective was to examine how parents and youth cope with persistent concussion symptoms and navigating the school system after diagnosis of PCS. Methods/approach Two focus groups were conducted: one with youth who developed PCS and one with their parents. A semi-structured interview including questions regarding concussion symptoms and academic experiences and accommodations was administered. Interviews were audio-recorded, transcribed, and analysed to identify themes. Results Parent (n = 6) and youth (n = 6) focus groups identified three common themes: (1) a need for the school system to have increased understanding of PCS and improved academic accommodations for these students; (2) PCS was associated with mental health complications (e.g., feelings of isolation) and pressure upon returning to school; and (3) parental frustration associated with managing return to learn expectations and their child’s recovery. Two contrasting themes between parent and youth groups emerged. First, parents experienced guilt because they questioned if their child exaggerated symptoms verse youth report of only lying about feeling better to return to everyday activities. Second, parents and youth differed on whether the youth felt bullied. Conclusions PCS youth face challenges when returning to school and expressed a desire for increased academic understanding/accommodation. This is attainable through increased awareness and education in the schools. To improve parent and youth mental health during recovery from PCS, support groups may aide to decrease feelings of isolation and frustration. Significance and contributions The findings bring attention for improved PCS education in the school system, as well as the need for community support of families who have a child diagnosed with PCS.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To describe and assess the evidence from controlled trials on the efficacy and tolerability of pharmacological interventions by any route of administration versus placebo or other drug treatments for acute attacks of migraine in children.