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To the Editor.-- Birken and Parkin have performed a useful service in identifying "In which journals will pediatricians find the best evidence for clinical practice?" (Pediatrics 1999;103:941-947). Had they not [...]

Objective: To assess the cost-effectiveness of an evidence-informed institutional protocol for physicians that encouraged management of children with newly diagnosed immune thrombocytopenia with observation over active therapy, where appropriate.Study Design: We conducted a probabilistic cost-effectiveness analysis from an institutional perspective using a decision tree with a one year time horizon. Patient-level data was retrospectively ascertained for children diagnosed in pre-protocol (2007-2009) and post-protocol (2013-2018) time periods. ITP resolution was defined as achieving a sustained platelet count of >100×103/μL at 9-12 months after diagnosis. Outpatient care and inpatient costs were obtained from the institution and provincial sources. Intervention costs accounted for QI initiative preparation and staff physician training. Incremental costs, incremental effects, and confidence intervals were calculated from 10 000 model iterations.Results: Forty-eight patients were followed for one year in the pre-protocol period and 84 in the post-protocol period. After protocol implementation, an average cost savings per child managed of $2055 (95% CI: $656, $3890) CAD was observed, as was a higher proportion of resolved ITP cases. The implementation strategy remained less costly and more effective in 99.7% of model iterations.Conclusions: Implementation of an evidence-informed institutional protocol to guide physicians towards increased uptake of observation over active therapy when managing children with newly diagnosed ITP resulted in significant cost savings on a per case basis, even after accounting for training-related costs. Though the long-term cost implications regarding the sustainability of the intervention are not yet known, it is anticipated that continued institutional savings could occur. [ABSTRACT FROM AUTHOR]

Importance: Epidemiological studies support a link between low 25-hydroxyvitamin D levels and a higher risk of viral upper respiratory tract infections. However, whether winter supplementation of vitamin D reduces the risk among children is unknown.Objective: To determine whether high-dose vs standard-dose vitamin D supplementation reduces the incidence of wintertime upper respiratory tract infections in young children.Design, Setting, and Participants: A randomized clinical trial was conducted during the winter months between September 13, 2011, and June 30, 2015, among children aged 1 through 5 years enrolled in TARGet Kids!, a multisite primary care practice-based research network in Toronto, Ontario, Canada.Interventions: Three hundred forty-nine participants were randomized to receive 2000 IU/d of vitamin D oral supplementation (high-dose group) vs 354 participants who were randomized to receive 400 IU/d (standard-dose group) for a minimum of 4 months between September and May.Main Outcome Measures: The primary outcome was the number of laboratory-confirmed viral upper respiratory tract infections based on parent-collected nasal swabs over the winter months. Secondary outcomes included the number of influenza infections, noninfluenza infections, parent-reported upper respiratory tract illnesses, time to first upper respiratory tract infection, and serum 25-hydroxyvitamin D levels at study termination.Results: Among 703 participants who were randomized (mean age, 2.7 years, 57.7% boys), 699 (99.4%) completed the trial. The mean number of laboratory-confirmed upper respiratory tract infections per child was 1.05 (95% CI, 0.91-1.19) for the high-dose group and 1.03 (95% CI, 0.90-1.16) for the standard-dose group, for a between-group difference of 0.02 (95% CI, -0.17 to 0.21) per child. There was no statistically significant difference in number of laboratory-confirmed infections between groups (incidence rate ratio [RR], 0.97; 95% CI, 0.80-1.16). There was also no significant difference in the median time to the first laboratory-confirmed infection: 3.95 months (95% CI, 3.02-5.95 months) for the high-dose group vs 3.29 months (95% CI, 2.66-4.14 months) for the standard-dose group, or number of parent-reported upper respiratory tract illnesses between groups (625 for high-dose vs 600 for standard-dose groups, incidence RR, 1.01; 95% CI, 0.88-1.16). At study termination, serum 25-hydroxyvitamin D levels were 48.7 ng/mL (95% CI, 46.9-50.5 ng/mL) in the high-dose group and 36.8 ng/mL (95% CI, 35.4-38.2 ng/mL) in the standard-dose group.Conclusions and Relevance: Among healthy children aged 1 to 5 years, daily administration of 2000 IU compared with 400 IU of vitamin D supplementation did not reduce overall wintertime upper respiratory tract infections. These findings do not support the routine use of high-dose vitamin D supplementation in children for the prevention of viral upper respiratory tract infections.Trial Registration: clinicaltrials.gov Identifier: NCT01419262. [ABSTRACT FROM AUTHOR]

The objective of this study was to evaluate the association of vitamin D intake and serum levels with fracture risk in children under 6 years of age. A case-control study was conducted in Toronto, Ontario, Canada. Cases were recruited from the fracture clinic at the Hospital for Sick Children, and matched controls were obtained from the TARGet Kids! primary-care research network. Controls were matched to cases on age, sex, height, and season. Fracture risk was estimated from conditional logistic regression, with adjustment for skin type, fracture history, waist circumference, outdoor free play, neighborhood income, soda consumption, and child's birth weight. A total of 206 cases were recruited during May 2009--April 2013 and matched to 343 controls. Serum 25-hydroxyvitamin D concentration (per 10-nmol/L increment: adjusted odds ratio (aOR) = 0.95, 95% confidence interval (CI): 0.88, 1.03) and intake of cow's milk (<2 cups/day vs. 2 cups/day: aOR = 0.95 (95% CI: 0.60, 1.52); >2 cups/day vs. 2 cups/day: aOR = 1.39 (95% CI: 0.85, 2.23)) were not significantly associated with reduced odds of fracture. A statistically significant association was observed between child use of vitamin D supplements and decreased odds of fracture (yes vs. no: aOR = 0.42, 95% CI: 0.25,0.69). Vitamin D supplementation, but not serum 25-hydroxyvitamin D level or milk intake, was associated with reduced fracture risk among these healthy young children. [ABSTRACT FROM AUTHOR]

Background: Communication delays are often the first presenting problem in infants with a range of developmental disabilities. Our objective was to assess the validity of the 18-month Nipissing District Developmental Screen compared with the Infant Toddler Checklist, a validated tool for detecting expressive language and other communication delays. Methods: A cross-sectional design was used. Children aged 18-20 months were recruited during scheduled health supervision visits. Parents completed both the 18-month Nipissing District Developmental Screen and the Infant Toddler Checklist. We assessed criterion validity (diagnostic test properties, overall agreement) for 1 or more "no" responses (1+NDDS flag) and 2 or more "no" responses (2+NDDS flag) using the Infant Toddler Checklist as a criterion measure. Results: The study included 348 children (mean age 18.6 ± 0.7 mo). The 1+NDDS flag had good sensitivity (94%, 95% confidence interval [CI] 70%-100%, and 86%, 95% CI 64%-96%), poor specificity (63%, 95% CI 58%-68%, and 63%, 95% CI 58%-69%), and fair agreement (0.26) to identify expressive speech and other communication delays, respectively. The 2+NDDS flag had low to fair sensitivity (50%, 95% CI 26%-74%, and 73%, 95% CI 50%--88%), good specificity (86%, 95% CI 82%-90%, and 88%, 95% CI 84%-92%) and moderate agreement (0.45) to identify expressive speech and other communication delays, respectively. Interpretation: The low specificity of the 1+NDDS flag may lead to overdiagnosis, and the low sensitivity of the 2+NDDS flag may lead to underdiagnosis, suggesting that infants who could benefit from early intervention may not be identified. The Nipissing District Developmental Screen does not have adequate characteristics to accurately identify children with a range of communication delays. [ABSTRACT FROM AUTHOR]

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Objectives: Fe-deficiency anaemia (IDA) occurs in 1-2 % of infants in developed countries, peaks at 1-3 years of age and is associated with later cognitive deficits. The objectives of the present study were to describe the characteristics of young children with severe IDA and examine modifiable risk factors in a developed-country setting.Design: Two prospective samples: a national surveillance programme sample and a regional longitudinal study sample.Setting: Canada, 2009-2011.Subjects: Two samples of young children recruited from community-based health-care practices: a national sample with severe anaemia (Hb<80 g/l) due to Fe deficiency and a regional sample with non-anaemic Fe sufficiency.Results: Children with severe IDA (n 201, mean Hb 55·1 g/l) experienced substantial morbidity (including developmental delay, heart failure, cerebral thrombosis) and health-care utilization (including a 42 % hospitalization rate). Compared with children with Fe sufficiency (n 597, mean Hb 122·4 g/l), children with severe IDA consumed a larger volume of cow's milk daily (median 1065 ml v. 500 ml, P<0·001) and were more likely to be using a bottle during the day (78 % v. 43 %, OR=6·0; 95 % CI 4·0, 8·9) and also in bed (60 % v. 21 %, OR=6·5; 95 % CI 4·4, 9·5).Conclusions: Severe IDA is associated with substantial morbidity and may be preventable. Three potentially modifiable feeding practices are associated with IDA: (i) cow's milk consumption greater than 500 ml/d; (ii) daytime bottle use beyond 12 months of age; and (iii) bottle use in bed. These feeding practices should be highlighted in future recommendations for public health and primary-care practitioners. [ABSTRACT FROM AUTHOR]

Objectives: To examine the relationship between family immigrant status and unscheduled 7-day revisits to the emergency department (ED) and to test this relationship within subgroups of immigrants by visa class (family, economic, refugee), native tongue on landing in Canada, and region of origin.Study Design: Population-based cohort study that used multiple linked health administrative and demographic datasets of landed immigrant and nonimmigrant children (<18 years) in urban Ontario who visited an ED and were discharged between April 2003 and March 2010. Logistic regression was used to model the odds of 7-day ED revisits with family immigrant status, with adjustment for patient and ED characteristics.Results: Of 3,322,901 initial visits to the ED, 249,648 (7.5%) resulted in a 7-day revisit. There was no significant association of immigrant status with either ED revisits or poor revisit outcomes (greater acuity visit or need for admission) in the adjusted models. Within immigrants, the odds of revisit were not associated with immigrant classes or region of origin; however, immigrants whose native tongue was not English or French had a slightly greater odds of revisiting the ED (aOR 1.05; 95% CI 1.01, 1.09). Significant predictors of revisits included younger age, greater triage acuity score, greater predilection for using an ED, daytime shifts, and greater deprivation index.Conclusions: Immigrant children are not more likely to have short-term revisits to the ED, but there may be barriers to care related to language fluency that need to be addressed. These findings may be relevant for improving translation services in EDs. [ABSTRACT FROM AUTHOR]

Background: Obesity has its origins in early childhood; however, there is limited evidence of the association between anthropometric indicators and cardiometabolic risk factors in young children. Our aim was to evaluate the associations between body mass index (BMI) and waist circumference (WC) in relation to cardiometabolic risk factors and to explore the clustering of these factors.Methods: A cross-sectional study was conducted in children aged 1-5 years through TARGet Kids! (n = 2917). Logistic regression was used to evaluate associations between BMI and WC z-scores and individual traditional and possible non-traditional cardiometabolic risk factors. The underlying clustering of these measures was evaluated using principal components analysis (PCA).Results: Child obesity (BMI z-score >2) was associated with high (>90th percentile) leptin [odds ratio (OR) 8.15, 95% confidence interval (CI) 4.56, 14.58] and insulin (OR = 1.76; 95% CI 1.05, 2.94). WC z-score >1 was associated with high insulin (OR 1.59, 95% CI 1.11, 2.28), leptin (OR 5.48, 95% CI 3.48, 8.63) and 25-hydroxyvitamin D < 75 nmol/L (OR 1.39, 95% CI 1.08, 1.79). BMI and WC were not associated with other traditional cardiometabolic risk factors, including non-High Density Lipoprotein (HDL) cholesterol, and glucose. Among children 3-5 years (n = 1035) the PCA of traditional risk factors identified three components: adiposity/blood pressure, metabolic, and lipids. The inclusion of non-traditional risk factors identified four additional components but contributed minimally to the total variation explained.Conclusions: Anthropometric indicators are associated with selected cardiometabolic risk factors in early childhood, although the clustering of risk factors suggests that adiposity is only one distinct component of cardiometabolic risk. The measurement of other risk factors beyond BMI and WC may be important in defining cardiometabolic risk in early childhood. [ABSTRACT FROM AUTHOR]

Background: It is unknown if young children's parent-reported physical activity and sedentary time are correlated with direct measures. The study objectives were to compare parent-reported physical and sedentary activity versus directly measured accelerometer data in early childhood. Methods: From 2013 to 2014, 117 healthy children less than 6 years of age were recruited to wear Actical accelerometers for 7 days. Accelerometer data and questionnaires were available on 87 children (74 %). Average daily physical activity was defined as the sum of activity ≥100 counts per minute, and sedentary time as the sum of activity <100 counts per minute during waking hours. Parents reported daily physical activity (unstructured free play in and out of school, and organized activities) and selected sedentary behaviors (screen time, stroller time, time in motor vehicle). Spearman correlation coefficients and Bland-Altman plots were used to assess the validity of parent-reported measures compared to accelerometer data. Results: Total physical activity was significantly greater when measured by accelerometer than parent-report; the median difference was 131 min/day (p < 0.001). Parent-reported child physical activity was weak to moderately correlated with directly measured total physical activity (r = 0.39, 95 % CI 0.19, 0.56). The correlations between types of physical activity (unstructured free play in and outside of school/daycare, and organized structured activity) and accelerometer were r = 0.30 (95 % CI 0.09, 0.49); r = 0.42 (95 % CI 0.23, 0.58); r = 0.26 (95 % CI 0.05, 0.46), respectively. There was no correlation between parent-reported and accelerometer-measured total sedentary time in children (r = 0.10, 95 % CI -0.12, 0.33). When the results were stratified by age group (<18, 18-47, and 48-70 months of age) no statistically significant correlations were observed and some inverse associations were observed. Conclusions: The correlation between parent-report of young children's physical activity and accelerometer-measured activity was weak to moderate depending on type of activity and age group. Parent-report of children's sedentary time was not correlated with accelerometer-measured sedentary time. Additional validation studies are needed to determine if parent-reported measures of physical activity and sedentary time are valid among children less than 6 years of age and across these young age groups. [ABSTRACT FROM AUTHOR]