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Purpose: Measuring ethnicity accurately is important for identifying ethnicity variations in disease risk. We evaluated the degree of agreement and accuracy of maternal ethnicity measured using the new standardized closed-ended geographically based ethnicity question and geographic reclassification of open-ended ethnicity questions from the Canadian census., Methods: A prospectively designed study of respondent agreement of mothers of healthy children aged 1-5 years recruited through the TARGet Kids! practice-based research network. For the primary analysis, the degree of agreement between geographic reclassification of the Canadian census maternal ethnicity variables and the new geographically based closed-ended maternal ethnicity variable completed by the same respondent was evaluated using a kappa analysis., Results: Eight hundred sixty-two mothers who completed both measures of ethnicity were included in the analysis. The kappa agreement statistic for the two definitions of maternal ethnicity was 0.87 (95% confidence interval, 0.84-0.90) indicating good agreement. Overall accuracy of the measurement was 93%. Sensitivity and specificity ranged from 83% to 100% and 96% to 100%, respectively., Conclusions: The new standardized closed-ended geographically based ethnicity question represents a practical alternative to widely used open-ended ethnicity questions. It may reduce risk of misinterpretation of ethnicity by respondents, simplify analysis, and improve the accuracy of ethnicity measurement., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Vitamin D levels are alarmingly low (<75 nmol/L) in 65-70% of North American children older than 1 year. An increased risk of viral upper respiratory tract infections (URTI), asthma-related hospitalizations and use of anti-inflammatory medication have all been linked with low vitamin D. No study has determined whether wintertime vitamin D supplementation can reduce the risk of URTI and asthma exacerbations, two of the most common and costly illnesses of early childhood. The objectives of this study are: 1) to compare the effect of 'high dose' (2000 IU/day) vs. 'standard dose' (400 IU/day) vitamin D supplementation in achieving reductions in laboratory confirmed URTI and asthma exacerbations during the winter in preschool-aged Canadian children; and 2) to assess the effect of 'high dose' vitamin D supplementation on vitamin D serum levels and specific viruses that cause URTI., Methods/design: This study is a pragmatic randomized controlled trial. Over 4 successive winters we will recruit 750 healthy children 1-5 years of age. Participating physicians are part of a primary healthcare research network called TARGet Kids!. Children will be randomized to the 'standard dose' or 'high dose' oral supplemental vitamin D for a minimum of 4 months (200 children per group). Parents will obtain a nasal swab from their child with each URTI, report the number of asthma exacerbations and complete symptom checklists. Unscheduled physician visits for URTIs and asthma exacerbations will be recorded. By May, a blood sample will be drawn to determine vitamin D serum levels. The primary analysis will be a comparison of URTI rate between study groups using a Poisson regression model. Secondary analyses will compare vitamin D serum levels, asthma exacerbations and the frequency of specific viral agents between groups., Discussion: Identifying whether vitamin D supplementation of preschoolers can reduce wintertime viral URTIs and asthma exacerbations and what dose is optimal may reduce population wide morbidity and associated health care and societal costs. This information will assist in determining practice and health policy recommendations related to vitamin D supplementation in healthy Canadian preschoolers.

Background: Vaccination is an important strategy in the prevention of influenza, but immunologic response to vaccination can vary widely. Recent studies have shown an association between serum 25-hydroxyvitamin D (25[OH]D) levels and immune function. The purpose of this study was to determine if serum 25(OH)D level correlates with influenza vaccine immunogenicity in children and adolescents., Methods: We conducted a prospective cohort study of children age 3 to 15 years of age vaccinated with trivalent influenza vaccine (A/Brisbane/59/2007[H1N1]-like virus, A/Brisbane/10/2007 [H3N2]-like virus and B/Florida/4/2006-like virus) in Hutterite communities in Alberta, Saskatchewan and Manitoba. Serum 25(OH)D levels were measured at baseline and immunogenicity was assessed using hemagluttination inhibition (HAI) titers done at baseline and 3-5 weeks post vaccination. Logistic regression was used to assess the relationship between serum 25(OH)D level as both a continuous and dichotomous variable and seroprotection, seroconversion, fold increase in geometric mean titer (GMT) and post vaccination titer., Results: A total of 391 children and adolescents were included in the study and 221 (57% had post-vaccination HAI titers. The median serum 25(OH)D level was 61.0 nmol/L (Interquartile range [IQR] 50.0, 71.0). No relationship was found between serum 25(OH)D level and seroprotection (post-vaccination titer ≥ 40 and ≥ 320) or seroconversion (post-vaccination titer ≥ 40 for participants with pre-vaccine titer <10 or four-fold rise in post-vaccination titer for those with a pre-vaccine titer ≥ 10)., Conclusion: Serum 25(OH)D level was not associated with influenza vaccine immunogenicity in otherwise healthy children and adolescents. Other strategies to enhance influenza vaccine response should continue to be evaluated in this population. The role of serum 25(OH)D level in vaccine responsiveness in other populations, especially those hyporesponsive to influenza vaccination, requires further study.

Background: Acute meningitis is a relatively common phenomenon in children. Identifying which children are most likely to have bacterial meningitis vs. self-limiting aseptic meningitis is important, as these children require investigation and antibiotic treatment., Objective: Our aim was to systematically identify and review the quality and performance of published clinical prediction rules (CPRs) for children with suspected bacterial meningitis., Methods: Medline and Embase were searched for CPRs involving children 0-18 years of age with suspected bacterial meningitis, with cerebral spinal fluid (CSF) culture used as the reference diagnostic standard. CPR quality was assessed using 17 previously published items. CPR performance was evaluated using sensitivity, negative likelihood ratio, and the treatment frequency that would result if the rule was used., Results: Eleven studies involving 6675 children with acute meningitis fulfilled all inclusion criteria and were entered in the study. They all describe the derivation or validation of six unique CPRs. A rigorously developed, high-performing, and well-validated CPR ready for clinical use to guide which children with suspected bacterial meningitis should be hospitalized and treated with intravenous antibiotics and which can be safely discharged home was not identified. Areas for quality improvement for future CPR studies include prospective validation using standardized inclusion criteria, adequate blinding, predictor reproducibility assessment, and meticulous follow-up of outcomes. The Bacterial Meningitis Score had the highest quality and performance and is the best candidate for prospective validation., Conclusions: Until consistently high methodological quality and diagnostic performance are demonstrated through prospective validation, caution is warranted in the routine clinical use of existing CPRs for children with suspected bacterial meningitis., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Modifiable behaviours during early childhood may provide opportunities to prevent disease processes before adverse outcomes occur. Our objective was to determine whether young children's eating behaviours were associated with increased risk of cardiovascular disease in later life., Methods: In this cross-sectional study involving children aged 3-5 years recruited from 7 primary care practices in Toronto, Ontario, we assessed the relation between eating behaviours as assessed by the NutriSTEP (Nutritional Screening Tool for Every Preschooler) questionnaire (completed by parents) and serum levels of non-high-density lipoprotein (HDL) cholesterol, a surrogate marker of cardiovascular risk. We also assessed the relation between dietary intake and serum non-HDL cholesterol, and between eating behaviours and other laboratory indices of cardiovascular risk (low-density lipoprotein [LDL] cholesterol, apolipoprotein B, HDL cholesterol and apoliprotein A1)., Results: A total of 1856 children were recruited from primary care practices in Toronto. Of these children, we included 1076 in our study for whom complete data and blood samples were available for analysis. The eating behaviours subscore of the NutriSTEP tool was significantly associated with serum non-HDL cholesterol (p = 0.03); for each unit increase in the eating behaviours subscore suggesting greater nutritional risk, we saw an increase of 0.02 mmol/L (95% confidence interval [CI] 0.002 to 0.05) in serum non-HDL cholesterol. The eating behaviours subscore was also associated with LDL cholesterol and apolipoprotein B, but not with HDL cholesterol or apolipoprotein A1. The dietary intake subscore was not associated with non-HDL cholesterol., Interpretation: Eating behaviours in preschool-aged children are important potentially modifiable determinants of cardiovascular risk and should be a focus for future studies of screening and behavioural interventions.

Background: Vitamin D may be important for immune function. Studies to date have shown an inconsistent association between vitamin D and infection with respiratory viruses. The purpose of this study was to determine if serum 25-hydroxyvitamin D (25(OH)D) was associated with laboratory-confirmed viral respiratory tract infections (RTIs) in children., Methods: Serum 25(OH)D levels were measured at baseline and children from Canadian Hutterite communities were followed prospectively during the respiratory virus season. Nasopharyngeal specimens were obtained if symptoms developed and infections were confirmed using polymerase chain reaction. The association between serum 25(OH)D and time to laboratory-confirmed viral RTI was evaluated using a Cox proportional hazards model., Results: Seven hundred forty-three children aged 3-15 years were followed between 22 December 2008 and 23 June 2009. The median serum 25(OH)D level was 62.0 nmol/L (interquartile range, 51.0-74.0). A total of 229 participants (31%) developed at least 1 laboratory-confirmed viral RTI. Younger age and lower serum 25(OH)D levels were associated with increased risk of viral RTI. Serum 25(OH)D levels <75 nmol/L increased the risk of viral RTI by 50% (hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.10-2.07, P = .011) and levels <50 nmol/L increased the risk by 70% (HR, 1.67; 95% CI, 1.16-2.40, P = .006)., Conclusions: Lower serum 25(OH)D levels were associated with increased risk of laboratory-confirmed viral RTI in children from Canadian Hutterite communities. Interventional studies evaluating the role of vitamin D supplementation to reduce the burden of viral RTIs are warranted.

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

OBJECTIVES To determine the effect of modifiable dietary intake variables (current vitamin D supplementation and daily cow's milk intake) on 25-hydroxyvitamin D level in early childhood and to evaluate the relationship between these modifiable dietary factors and other largely nonmodifiable determinants of vitamin D status including skin pigmentation and season. DESIGN Cross-sectional study. SETTING Primary care pediatric and family medicine practices participating in the TARGet Kids! practice-based research network in Toronto, Ontario, Canada. PARTICIPANTS From December 2008 to June 2011, healthy children 1 to 5 years of age were recruited during a routine physician's visit. INTERVENTIONS Survey, anthropometric measurements, and laboratory data were collected. A multivariable linear regression model was developed to examine the independent effects of vitamin D supplementation and daily volume of cow's milk on 25-hydroxyvitamin D level. MAIN OUTCOME MEASURES 25-Hydroxyvitamin D level. RESULTS Blood was obtained in 1898 children. Two modifiable dietary intake variables, vitamin D supplementation and cow's milk, increased 25-hydroxyvitamin D level by 3.4 ng/mL (95% CI, 2-4 ng/mL) and 1.6 ng/mL per 250-mL cup per day (95% CI, 1-2 ng/mL), respectively. Two nonmodifiable variables reflecting cutaneous vitamin D synthesis (skin pigmentation and season) were also strongly associated with 25-hydroxyvitamin D status but accounted for a much smaller proportion of the explained variation in 25-hydroxyvitamin D level. The effect of vitamin D supplementation and milk intake on 25-hydroxyvitamin D level appeared similar regardless of skin pigmentation or season. CONCLUSION Two modifiable dietary intake variables (vitamin D supplementation and cow's milk intake) are the most important determinants of 25-hydroxyvitamin D status in early childhood.

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

Objectives: To systematically identify clinical prediction rules (CPRs) for children with suspected appendicitis and compare their methodological quality and performance., Study Design and Setting: Included studies involved children aged 0-18 years with suspected appendicitis identified through MEDLINE and EMBASE from 1950 to 2012. The quality was assessed using 17 previously published items. The performance was evaluated using the sensitivity, negative likelihood ratio, and predicted frequency of appendicitis diagnosis that would result if the rule was used., Results: Twelve studies fulfilled the inclusion criteria describing the derivation or validation of six unique CPRs involving 4,201 children with suspected appendicitis. Migratory pain, nausea or vomiting, and right lower quadrant tenderness were common predictors to all rules. Methodological quality varied widely. The most poorly addressed quality items were the predictor and outcome assessor blinding, predictor description, and reproducibility of predictor assessment. The most well-validated CPRs were the Pediatric Appendicitis Score (PAS) and MANTRELS (Migration, Anorexia, Nausea/vomiting, Tenderness in the right lower quadrant, Rebound pain, Elevation in temperature, Leukocytosis, Shift to the left)/Alvarado Score. Overall, the PAS validation studies outperformed the Alvarado validation studies., Conclusion: The PAS and Alvarado scores were the most well validated but neither met the current performance benchmarks. A high quality, well validated, and consistently high-performing CPR was not identified. Further research is needed before a CPR for children with suspected appendicitis can be used in routine practice., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To determine whether safety warnings issued by health regulatory agencies regarding desmopressin treatment influenced treatment rates among children., Patient Population and Methods: We conducted a time-series analysis using health administrative data from Ontario, Canada, between January 1, 2003 and March 31, 2010. We examined desmopressin prescribing rates among children (<13 years) and investigated the impact of a United States Food and Drug Administration warning (December 2007) and a subsequent Health Canada warning (July 2008) on these rates. A secondary analysis stratified rates according to route of administration., Results: On average, quarterly desmopressin treatment rates were 29.8% lower following the two warnings (4.7 per 1000 population) compared with the period prior to warnings being issued (6.7 per 1000 population). Structural break analyses identified a significant decrease in overall desmopressin prescribing rates in Q3 2008, with the 95% confidence interval (CI) spanning both safety warnings (Q4 2007 to Q1 2009). A secondary analysis of prescribing rates for oral formulations found consistent results (structural break Q4 2008, 95% CI Q2 2007 to Q2 2009). The average quarterly prescribing rate of intranasal formulations declined by 73.1% following the warnings compared with the period preceding the warnings., Conclusion: Safety warnings issued by regulatory agencies dramatically influenced desmopressin use among Ontario's children., (Copyright © 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

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

Objectives: To determine the prevalence of low vitamin D concentrations in a cohort of healthy two-year-old children living in a large Canadian city, and to explore whether body mass index (BMI) and cow's milk intake are associated with low vitamin D concentrations., Methods: A cross-sectional study was performed on healthy two-year-old children attending a well-child visit in Toronto, Ontario (latitude 43.4°N). Dietary exposures were measured by questionnaire. The primary outcome was the prevalence of low vitamin D concentrations (25-hydroxyvitamin D concentration of lower than 50 nmol/L or lower than 75 nmol/L)., Results: A total of 91 healthy children 24 to 30 months of age were recruited between November 2007 and May 2008. The prevalence of low vitamin D concentrations (lower than 50 nmol/L) was 32% (29 of 92, 95% CI 22% to 42%) and the prevalence of vitamin D concentrations of lower than 75 nmol/L was 82% (75 of 91, 95% CI 73% to 89%). Using multivariable logistic regression, the odds of vitamin D concentrations being lower than 50 nmol/L decreased by 0.44 (95% CI 0.2 to 0.96) for each additional cup of cow's milk intake per day and increased by 1.2 to 2.6 per unit BMI depending on BMI level (P=0.07)., Conclusions: A total of 30% to 80% of toddlers in the present study's urban Canadian setting demonstrated low vitamin D concentrations - the highest prevalence of low vitamin D in toddlers outside of Alaska. Modifiable factors associated with low vitamin D were lower cow's milk intake and higher BMI. The vitamin D status of toddlers in urban Canada may require specific attention.

Objective: The goal was to determine whether an office-based, educational intervention for parents of 9-month-old children could reduce bottle use and iron depletion at 2 years of age., Methods: Between January 2006 and 2007, 251 healthy, 9-month-old infants attending a routine health maintenance visit were assigned randomly to intervention or control groups. Parents in the intervention group were introduced to a 1-week protocol to wean their children from the bottle. Iron depletion (ferritin levels of <10 microg/L) and bottle use at 2 years were assessed., Results: A total of 201 children were monitored to 2 years of age (follow-up rate: 81%). Rates of iron depletion (10 [10%] of 102 children vs 13 [13%] of 99 children; P = .42) and milk consumption of >16 oz (16 [16%] of 102 children vs 17 [17%] of 99 children; P = .7) were not significantly different between the 2 groups at 2 years of age. However, children in the intervention group started using a cup 3 months earlier (9 vs 12 months; P = .001), were weaned from the bottle 4 months earlier (12 vs 16 months; P = .004), and were more than one-half as likely to be using a bottle at 2 years of age (15 [15%] of 102 children vs 39 [40%] of 99 children; P = .0004)., Conclusions: This simple intervention administered during a health maintenance visit did not result in a decrease in iron depletion at 2 years of age but did result in a 60% reduction in prolonged bottle use.

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

Objective: Iron-deficiency anemia occurs with a peak prevalence of 4% to 8% in children between 1 and 3 years of age. Case reports have suggested an association between iron-deficiency anemia in healthy children and ischemic stroke. Our objective was to investigate whether iron-deficiency anemia is associated with stroke in young children., Methods: A case-control study was conducted of case patients who were selected from the stroke registry at the Hospital for Sick Children (Toronto, Ontario, Canada) and control subjects selected from a database of healthy children who were prospectively enrolled in an outpatient setting. Children were aged 12 to 38 months and were previously healthy with no identifiable risk factors for stroke. Age, gender, mean corpuscular volume, platelet count, and hemoglobin and ferritin levels were collected. Iron-deficiency anemia was defined as a hemoglobin level of <110 g/L, mean corpuscular volume <73 fL, and serum ferritin level <12 microg/L. Stroke was defined according to clinical and radiologic criteria., Results: Case (n = 15) and control (n = 143) subjects were similar with respect to median age and percentage of boys. Case patients had a lower median hemoglobin level and mean corpuscular volume and a higher median platelet count. Iron-deficiency anemia was significantly more common among case patients (8 [53%] of 15) than control subjects (13 [9%] of 143)., Conclusions: Previously healthy children with stroke were 10 times more likely to have iron-deficiency anemia than healthy children without stroke. Furthermore, children with iron-deficiency anemia accounted for more than half of all stroke cases in children without an underlying medical illness, which suggests that iron-deficiency anemia is a significant risk factor for stroke in otherwise healthy young children. Primary prevention and early identification of iron-deficiency anemia must remain a priority.

Objective: To determine whether a paediatric after-hours clinic uses evidence-based management in the treatment of acute otitis media, and compare this management with that provided in a paediatric emergency department and a general hospital emergency department., Methods: A retrospective chart review of 573 patients (aged six months to five years) with a discharge diagnosis of acute otitis media was conducted in three after-hours settings: a paediatric after-hours clinic, a tertiary paediatric hospital emergency department and a secondary general hospital emergency department. The patients' age, weight, sex and allergy to antibiotics were recorded as baseline characteristics. The physicians' antibiotic choice, dose and duration, and the use of investigations were recorded as outcome variables., Results: Amoxicillin was prescribed to 68% of patients at both the paediatric after-hours clinic and the paediatric hospital emergency department, compared with 53% of patients at the general hospital emergency department (P<0.01). The mean dose of amoxicillin prescribed at the paediatric after-hours clinic and the paediatric hospital emergency department were similar (43.4±9.7 mg/kg per day and 42.4±14.3 mg/kg per day, respectively) and higher than that prescribed at the general hospital emergency department (38.6±8.8 mg/kg per day, P<0.01). The paediatric after-hours clinic used investigations less often than did emergency departments (0.5% of cases compared with 9% and 20%, P<0.01)., Conclusion: The paediatric after-hours clinic provided a high level of adherence to a clinical practice guideline and had a low utilization of resource intensive investigations.