Association of empiric antibiotic selection and clinical outcomes in hospitalised children with severe orbital infections: a retrospective cohort study

OBJECTIVE

To determine the association of initial empiric antibiotic regimens with clinical outcomes in hospitalised children with severe orbital infections.

DESIGN

Multi-centre observational cohort study using data from 2009 to 2018 clinical records.

SETTING

Canadian children's hospitals (7) and community hospitals (3).

PATIENTS

Children between 2 months and 18 years hospitalised for >24 hours with severe orbital infections.

INTERVENTIONS

Empiric intravenous antibiotic regimen in the first 24 hours of hospitalisation.

MAIN OUTCOME MEASURES

Length of hospital stay and surgical intervention using multivariable median regression and multivariate logistic regression, with adjustment for covariates.

RESULTS

Of 1421 patients, 60.0% were male and the median age was 5.5 years (IQR 2.4-9.9). Median length of stay was 86.4 hours (IQR 56.9-137.5) and 180 (12.7%) received surgical intervention. Patients receiving broad-spectrum empiric antibiotics had an increased median length of stay, ranging from an additional 13.8 hours (third generation cephalosporin and anaerobic coverage) to 19.5 hours (third generation cephalosporin, staphylococcal and anaerobic coverage). No antibiotic regimen was associated with a change in the odds of surgical intervention. These findings remained unchanged in sensitivity analyses restricted to more severely ill patients. There was a twofold increase in the percentage of patients receiving the broadest empiric antibiotic regimens containing both staphylococcal and anaerobic coverage from 17.8% in 2009 to 40.3% in 2018.

CONCLUSIONS

Empiric use of broad-spectrum antibiotics with staphylococci and anaerobic coverage was associated with longer length of stay and similar rates of surgery in children with orbital infections. There is an urgent need for comparative effectiveness studies of various antibiotic regimes.

Determinants of Anishinabeck infant and early childhood growth trajectories in Northwestern Ontario, Canada: a cohort study

BACKGROUND

The Developmental Origins of Health and Disease (DOHaD) paradigm emphasizes the significance of early life factors for the prevention of chronic health conditions, like type 2 diabetes (T2DM) and obesity, which disproportionately affect First Nations communities in Canada. Despite increasing DOHaD research related to maternal health during pregnancy, early childhood growth patterns, and infant feeding practices with many populations, data from First Nations communities in Canada are limited. In partnership with Sandy Lake First Nation, the aims of this project were to characterize birthweights and growth patterns of First Nations infants/children over the first 6 years of life and to study the impact of maternal and infant social and behavioral factors on birthweight and growth trajectories.

METHODS

We recruited 194 families through community announcements and clinic visits. Infant/child length/height and weight were measured at 1 and 2 weeks; 1, 2, 6, 12, and 18 months; and 2, 3, 4, 5 and 6 years. Maternal and infant/child questionnaires captured data about health, nutrition, and social support. Weight-for-Age z-score (WAZ), Height-for-Age z-score (HAZ), and BMI-for-Age z-score (BAZ) were calculated using WHO reference standards and trajectories were analyzed using generalized additive models. Generalized estimating equations and logistic regression were used to determine associations between exposures and outcomes.

RESULTS

WAZ and BAZ were above the WHO mean and increased with age until age 6 years. Generalized estimating equations indicated that WAZ was positively associated with age (0.152; 95% CI 0.014, 0.29), HAZ was positively associated with birthweight (0.155; 95% CI 0.035, 0.275), and BAZ was positively associated with caregiver's BMI (0.049; 95% CI 0.004, 0.090). There was an increased odds of rapid weight gain (RWG) with exposure to gestational diabetes (OR: 7.47, 95% CI 1.68, 46.22). Almost 70% of parents initiated breastfeeding, and breastfeeding initiation was modestly associated with lower WAZ (-0.18; 95% CI -0.64, 0.28) and BAZ (-0.23; 95% CI -0.79, 0.34).

CONCLUSIONS

This work highlights early life factors that may contribute to T2DM etiology and can be used to support community and Indigenous-led prevention strategies.

De-implementing low-value continuous pulse oximetry practice in infants hospitalized with bronchiolitis: A multicentre qualitative study

BACKGROUND

Clinical trial evidence supports the routine use of intermittent pulse oximetry in stabilized infants hospitalized with bronchiolitis. However, continuous pulse oximetry use is common.

OBJECTIVE

This study aimed to understand the barriers and facilitators to de-implement continuous pulse oximetry and implement intermittent pulse oximetry in infants hospitalized with stabilized bronchiolitis.

METHODS

This multicentre qualitative study interviewed attending pediatricians, residents, nurses, respiratory therapists, and caregivers of infants hospitalized with bronchiolitis at hospitals in Ontario, Canada, to explore beliefs, attitudes, and experiences regarding pulse oximetry use in bronchiolitis management. Data were analyzed using thematic analysis to understand barriers and facilitators to practice change, mapped to the Consolidated Framework for Implementation Research (CFIR) domains.

RESULTS

Sixty-seven participants from six hospitals were interviewed using individual interviews and focus groups. Healthcare providers emphasized the importance of identifying and understanding who is responsible for bedside pulse oximetry practice (physicians vs. nurses). Clinical experience, knowledge of guidelines, importance versus competing priorities, and the tensions among team members due to practice variation in monitoring, influenced monitoring practice. Nurses believed in the advantages of intermittent monitoring (reduced alarm fatigue, facilitation of timely discharges, and reduced workload). Clinicians identified ways to clarify indications for continuous monitoring (based on patient risk factors), versus indications to transition to intermittent monitoring (established oral feeding, sleeping without desaturations). Caregivers did not express a clear preference for monitoring type; rather, they described the need for clear communication around interpreting monitor readings, management decisions, and care transitions.

CONCLUSIONS

Understanding professional roles, clarity around local practice standards and supporting families' understanding of pulse oximetry practice is essential for practice change. These findings may inform hospital quality improvement efforts to de-implement continuous monitoring in bronchiolitis hospital care.

Current and new frontiers in hereditary cancer surveillance: Opportunities for liquid biopsy

At least 5% of cancer diagnoses are attributed to a causal pathogenic or likely pathogenic germline genetic variant (hereditary cancer syndrome-HCS). These individuals are burdened with lifelong surveillance monitoring organs for a wide spectrum of cancers. This is associated with substantial uncertainty and anxiety in the time between screening tests and while the individuals are awaiting results. Cell-free DNA (cfDNA) sequencing has recently shown potential as a non-invasive strategy for monitoring cancer. There is an opportunity for high-yield cancer early detection in HCS. To assess clinical validity of cfDNA in individuals with HCS, representatives from eight genetics centers from across Canada founded the CHARM (cfDNA in Hereditary and High-Risk Malignancies) Consortium in 2017. In this perspective, we discuss operationalization of this consortium and early data emerging from the most common and well-characterized HCSs: hereditary breast and ovarian cancer, Lynch syndrome, Li-Fraumeni syndrome, and Neurofibromatosis type 1. We identify opportunities for the incorporation of cfDNA sequencing into surveillance protocols; these opportunities are backed by examples of earlier cancer detection efficacy in HCSs from the CHARM Consortium. We seek to establish a paradigm shift in early cancer surveillance in individuals with HCSs, away from highly centralized, regimented medical screening visits and toward more accessible, frequent, and proactive care for these high-risk individuals.

38 Developmental Screening Using the Infant Toddler Checklist at 18 Months and School Readiness at 4 to 6 Years

Background

The American Academy of Pediatrics recommends developmental screening at multiple visits using both a general developmental tool and an autism spectrum disorder (ASD)-specific tool. The Canadian Paediatric Society recommends screening at a single visit at 18 months. There is no consensus on which tool is best suited for one-time screening. The Infant Toddler Checklist (ITC) identifies children who are at risk for communication impairment, may detect ASD, and may be a useful screening tool at the 18-month visit.

Objectives

To examine the screening test accuracy of the ITC at the 18-month visit to predict school readiness at kindergarten age.

Design/Methods

This prospective cohort study included children who attended primary care health supervision visits in Toronto, Canada. Parents completed the ITC at the 18-month visit and teachers completed the Early Development Instrument (EDI - a population-level measure of school readiness in kindergarten) at 4-6 years. An ITC screen is positive if there is concern for expressive speech delay (speech composite below the 10^th percentile) and/or other communication delay (social composite, symbolic composite or the total score below the 10^th percentile). Children were considered overall vulnerable on the EDI if at least one of five domains was below the 10^th percentile of the Ontario population: language and cognitive development; physical health and well-being; social competence; emotional maturity; communication skills and general knowledge. We calculated screening test properties with 95% confidence intervals (CIs), using EDI vulnerability as the criterion measure. We used multivariable regression models to examine the association between the ITC and EDI domains.

Results

Of 293 children, 30 (10%) had a positive ITC. At follow-up, 54 (18%) children had a teacher-reported EDI vulnerability. The specificity (range, 87%-96%) and negative predictive value (range, 83%-95%) for the ITC were high; false positive rate was low (range, 4%-13%); sensitivity was low (range, 11%-37%). A positive ITC was associated with a lower score in EDI language and cognitive development (b= -0.62, 95% CI: -1.25, -0.18; P=0.046) and EDI communication skills and general knowledge (b= -1.08, 95% CI: -2.10, -0.17; P=0.036). We found no evidence of an association between ITC and EDI vulnerability.

Conclusion

The ITC at 18 months had high specificity (87%-96%) suggesting that most children with a negative ITC will demonstrate school readiness at 4-6 years. False positive rates were low, minimizing over-diagnosis. The ITC, with its focus on speech and language, communication disorders and ASD, may be a candidate for screening at the 18-month visit.

75 Identifying High Priority Conditions for Research in Hospitalized Children Using a Data-driven Approach: A Population-based Study

Background

Identifying conditions that should be prioritized for research based on their healthcare system burden is imperative to build a meaningful research agenda for the care of hospitalized children. No previous Canadian prioritization studies have been conducted in this area.

Objectives

To determine the prevalence, cost, and variation in cost of pediatric hospitalizations at all hospital types, to identify conditions that should be prioritized for future research.

Design/Methods

Population-based cross-sectional study of children (< 18 years), with an inpatient hospital encounter between April 1, 2014 and March 31, 2019 in Ontario, Canada. Data were obtained from linked health administrative databases. For each encounter, the most responsible ICD-10-CA discharge diagnosis code was classified into clinical categories using the Pediatric Clinical Classification System. The condition-specific prevalence and cost of pediatric hospitalizations, and condition-specific variation in cost per encounter across hospitals were determined. The variation in cost was evaluated using number of outlier hospitals, and intraclass correlation coefficient (ICC).

Results

There were 627,314 inpatient hospital encounters from 165 hospitals costing $4.3 billion. A total of 408,003 (65.0%) hospitalizations and $1.9 billion (43.8%) in hospital costs occurred at general hospitals. Table 1 presents the 25 most prevalent and 25 most costly conditions (34 in total) ranked by cumulative cost. The top 10 costly conditions accounted for 70.0% of all costs and 59.6% of all encounters. Conditions that were highly prevalent and costly included: low birth weight, preterm newborn, major depressive disorder, pneumonia, other perinatal conditions, bronchiolitis, and neonatal hyperbilirubinemia. Figure 1 illustrates the 25 most costly medical conditions, of which the majority of the most prevalent and costly conditions were newborn conditions. Amongst the most costly conditions, the highest variations in cost across hospitals were observed in two mental health conditions (other mental health disorders [ICC = 0.28]; anxiety disorders [ICC = 0.19]), and three newborn conditions (intrauterine hypoxia and birth asphyxia [ICC = 0.27]; other perinatal conditions [ICC = 0.17]; surfactant deficiency disorder [ICC = 0.17]).

Conclusion

This study identified several newborn and mental health conditions as the most prevalent, costly, and with high variation in cost across hospitals in hospitalized children. These results can be used to generate a research agenda for the care of hospitalized children in general and children’s hospitals to build a stronger evidence-base and improve patient outcomes.

78 Cost-effectiveness of intermittent vs. continuous pulse oximetry monitoring in infants hospitalized with stabilized bronchiolitis: A multi-centre clinical trial

Background

Pulse oximetry is a non-invasive technology that is integral to the supportive care of hospitalized infants with bronchiolitis. A multi-centre, randomized trial comparing the effectiveness of intermittent vs. continuous pulse oximetry found similar hospital length of stay and safety outcomes, and greater nursing satisfaction with intermittent monitoring.

Objectives

To evaluate the cost-effectiveness of intermittent vs. continuous pulse oximetry in hospitalized infants with stabilized bronchiolitis.

Design/Methods

Prospective economic evaluation concurrent with a randomized trial (October 2016 to May 2019) using a probabilistic analysis. Infants (n=229) 4 weeks to 24 months hospitalized with bronchiolitis, with or without supplemental oxygen, after stabilization were randomized at six Ontario hospitals (community and children's) to intermittent (every 4 hours) vs. continuous pulse oximetry using an oxygen saturation target of 90% or higher. The main outcome measure for the economic evaluation was cost and incremental costs. The clinical effect measure was length of hospital stay in hours. The cost-effective analysis adopted a societal and health care system perspective and a time horizon from hospitalization to 15 days post-discharge. Patient level direct health care costs and indirect costs were included. Costs, health resource use and clinical outcomes were obtained from trial data. Publicly available pricing resources were used to supplement costs. Ranges for sensitivity analysis were based on 95% confidence intervals of the trial data. All costs were reported in 2020 Canadian dollars. This study was funded by a grant from the Canadian Institutes of Health Research.

Results

Trial data from 229 infants across six hospitals was included. Mean societal costs per patient were lower in the intermittent monitoring group: $6528 (95% CI: $3201, $12058) in the intermittent and $6815 (95% CI: $1454, $26485) in the continuous group with a mean incremental cost of -$287 (95% CI -$20084, $7842). Mean health care system costs per patient were $3992 (95% CI -$1139, $9224) in the intermittent and $4604 (95% CI -$317, $24126) in the continuous group (incremental cost -$613 (95% CI -$20564, $7089). The mean effect measure, length of stay, was also similar between the two groups: 36.3 hours in the intermittent group and 40.2 hours in the continuous group. One-way sensitivity analyses on all variables revealed that the findings were robust and the incremental costs were not sensitive to the uncertainty within the defined ranges.

Conclusion

In a prospective economic evaluation conducted with a clinical trial, we found that intermittent monitoring was less expensive than continuous monitoring, considering societal and health care costs. These findings support recommendations to use intermittent pulse oximetry monitoring in hospitalized infants with stabilized bronchiolitis.

76 Understanding practice change around intermittent versus continuous pulse oximetry in infants hospitalized with bronchiolitis: a multi-centre qualitative study

Background

Bronchiolitis is the most common reason for hospitalization in infants and is cumulatively costly for the healthcare system. Trial evidence and national guidelines support the routine use of intermittent pulse oximetry in stabilized (no oxygen supplementation) infants with bronchiolitis. However, continuous pulse oximetry use is common.

Objectives

To understand the barriers and facilitators important to de-implementing continuous pulse oximetry and implementing intermittent pulse oximetry in stabilized infants hospitalized with bronchiolitis.

Design/Methods

From December 2018 to January 2020, participants were recruited from six Ontario hospitals (3 community and 3 paediatric hospitals) in a multi-centre qualitative study. Focus groups were conducted with staff paediatricians, paediatric residents, nurses, and respiratory therapists. Interviews were conducted with caregivers of infants recently hospitalized with bronchiolitis. Participants' beliefs, attitudes, and experiences related to pulse oximetry use in bronchiolitis management were explored. Recordings were transcribed and analyzed using thematic analysis via NVivo software to understand barriers and facilitators to practice change. These were then mapped to the domains and the constructs of the Consolidated Framework for Implementation Research (CFIR).

Results

67 individuals from six hospitals participated. Themes relevant to understanding barriers and facilitators to de-implementing continuous and implementing intermittent monitoring were identified. Healthcare professionals emphasized the importance of identifying and understanding who is responsible for bedside monitoring practice (physician vs. nurses). Clinical experience, knowledge of guidelines (international and local practice), importance relative to competing priorities, and the tensions amongst team members due to practice variation all influenced monitoring practice. Nurses held beliefs around the advantages of intermittent monitoring (e.g., reduced alarm fatigue, facilitation of timely discharges and reduced workload). Clinicians identified ways to clarify indications for ongoing continuous monitoring (e.g., based on clinical risk factors such as medical complexity, prematurity, and age), vs. indications to transition to intermittent monitoring (e.g., established oral feeding, sleeping without desaturations, and off supplemental oxygen). Caregivers did not express a clear preference for monitoring type, but described the stress of having a child admitted to hospital with an emphasis on the need for clear communication around the interpretation of monitors, management decisions, and care transitions.

Conclusion

In this multi-centre qualitative study of clinicians and caregivers, we identified barriers and facilitators that are important to de-implementing continuous monitoring and implementing intermittent monitoring. Understanding professional roles, clarity around local practice standards and supporting families' understanding of pulse oximetry monitoring practices are essential for practice change.

66 Trends in bronchiolitis emergency department visits in Ontario, 2004-2018: A population-based cohort study

Background

Bronchiolitis is the most common lower respiratory tract infection in children and places a significant burden on the health care system. There have been few population-based studies describing trends in emergency department (ED) rates over time.

Objectives

To estimate population-based rates and trends of bronchiolitis ED visits from 2004 to 2018 in Ontario, Canada.

Design/Methods

We conducted a population-based cohort study of all children less than 2 years of age from April 1, 2004 to March 31, 2018 using linked administrative data. Bronchiolitis hospital encounters were identified using ICD-10 discharge diagnosis codes. The primary outcome was bronchiolitis ED visit rate estimated per 1000 person-years. Secondary outcomes included ED visit rate by subgroups (age, gestational age, birth weight, comorbidity, rurality, and material deprivation), bronchiolitis hospitalizations per 100 bronchiolitis ED visits, bronchiolitis ED 14-day revisit rate (ED revisit or hospitalization per 100 ED visits), and mortality rate (in- and out-of-hospital deaths per 1000 person-years). Annual percent change (APC) was estimated using log-linear regression models to determine trends in outcomes.

Results

Of the 2,336,446 infants less than 2 years of age during the study period, 93,843 children (4.0%) had 115,116 bronchiolitis ED visits at 208 hospitals. Bronchiolitis accounted for an increasing percentage of all-cause ED visits, from 7,446 (3.4%) of 216,122 in 2004-2005 to 9,702 (4.2%) of 231,693 in 2017-2018 (APC 2.2%; 95% CI [1.2-3.2]). Bronchiolitis ED visits per 1000 person-years increased by 26.7% from 27.0 (95% CI, 26.4-27.7) in 2004-2005 to 34.2 (95% CI, 33.5-34.9) in 2017-18 (APC=2.6%; 95% CI [1.5-3.8], p<0.001). Subgroup specific rates similarly increased over the study period. Hospitalizations per 100 ED visits decreased from 51.8 (95% CI, 50.2-53.4) in 2004-2005 to 37.0 (95% CI, 35.8-38.2) in 2017-2018 (APC -2.6% [95% CI, -3.3 to -1.8], p<0.0001). Revisits after an ED encounter were stable, 14.0 (95% CI, 13.0-15.0) in 2004-2005 and 11.8 (95% CI, 11.1-12.6) per 100 ED visits in 2017-2018 (APC -0.3%, [95% CI, -1.3 to 0.7]; p=0.68), as was the mortality rate (Figure 1).

Conclusion

In a population-based study from 2004 to 2018, bronchiolitis ED use increased significantly. However, the bronchiolitis hospitalizations declined relative to ED visits, and the ED revisit and mortality rate remained stable, suggesting that illness severity did not increase. These findings indicate an increasing health services burden of bronchiolitis on EDs.

Optic Pathway Glioma in Children with Neurofibromatosis Type 1: A Multidisciplinary Entity, Posing Dilemmas in Diagnosis and Management Multidisciplinary Management of Optic Pathway Glioma in Children with Neurofibromatosis Type 1

Introduction

Neurofibromatosis type 1 (NF1) has an incidence of 1 in 2,000 to 3,000 individuals and in 15% is associated with optic pathway glioma (OPG). Given the variability in clinical presentation and related morbidity, a multidisciplinary approach for diagnosis and management of children with NF1 and OPG is required, but often lacks coordination and regular information exchange. Herein we summarize our experience and describe the care pathways/network provided by a multidisciplinary team. The role of the distinct team members is elucidated as well as the care amendments made over time.

Methods

We performed a retrospective single-center observational study, including children treated at our institution between 1990 and 2021. Inclusion criteria were clinical diagnosis of NF1, radiographic and/or histopathological diagnosis of OPG and age below 18 years. Patients being treated elsewhere were excluded from the study. Data was abstracted from each child’s health record using a standardized data collection form. Characteristics of children with NF1 and OPG were described using means (SD) and percentages. Outcomes were determined using Kaplan-Meier estimates.

Results

From 1990 to 2021, 1,337 children were followed in our institution. Of those, 195 were diagnosed with OPG (14.6%), including 94 (48.21%) females and 101 (51.79%) males. Comprehensive data were available in 150 patients. The mean (SD) age at diagnosis was 5.31(4.08) years (range: 0.8–17.04 years). Sixty-two (41.3%) patients remained stable and did not undergo treatment, whereas 88 (58.7%) patients required at least one treatment. The mean (SD) duration of follow up was 8.14 (5.46) years (range: 0.1–25.9 years; median 6.8 years). Overall survival was of 23.6 years (±1.08), comprising 5 deaths. A dedicated NF clinic, including pediatricians and a nurse, provides regular follow up and plays a central role in the management of children with NF1, identifying those at risk of OPG, coordinating referrals to Neuroradiology and other specialists as indicated. All children are assessed annually by Ophthalmology. Comprehensive care was provided by a multidisciplinary team consisting of Dermatology, Genetics, Neuro-oncology, Neuroradiology, Neurosurgery, Ophthalmology and Pediatrics.

Conclusions

The care of children with NF1 and OPG is optimized with a multidisciplinary team approach, coordinated by a central specialty clinic.

Association Between Physical Activity, Screen Time and Sleep, and School Readiness in Canadian Children Aged 4 to 6 Years

OBJECTIVE

School readiness is strongly associated with a child's future school success and well-being. The primary objective of this study was to determine whether meeting 24-hour movement guidelines (national physical activity, sedentary behaviors, and sleep recommendations) was associated with school readiness measured with mean scores in each of the 5 developmental domains of the Early Development Instrument (EDI) in Canadian children aged 4 to 6 years. Secondary objectives include examining the following: (1) the association between meeting 24-hour movement guidelines and overall vulnerability in school readiness and (2) the association between meeting individual physical activity, screen use and sleep recommendations, and overall school readiness.

METHODS

A prospective cohort study was performed using data from children (aged 4-6 years) who participated in a large-scale primary care practice-based research network.

RESULTS

Of the 739 participants (aged 5.9 + 0.12 years) in this prospective cohort study, 18.2% met the 24-Hour Movement Guidelines. Linear regression models (adjusted for child/family demographic characteristics, number of siblings, immigration status, and annual household income) revealed no evidence of an association between meeting all 24-hour movement guidelines and any of the 5 domains of the EDI (p > 0.05). Adjusted linear regression models revealed evidence of an association between meeting screen use guidelines and the "language and cognitive development" (β = 0.16, p = 0.004) domain, and for the sleep guideline, there was a statistically significant association with the "physical health and well-being" (β = 0.23, p = 0.001), the "language and cognitive development" (β = 0.10, p = 0.003), and the "communication skills and general knowledge" (β = 0.18, p < 0.001) domain.

CONCLUSION

Early lifestyle interventions targeting screen use and sleep may be beneficial for improving a child's readiness for school.

Parenteral versus enteral fluid therapy for children hospitalised with bronchiolitis

BACKGROUND

The main focus of treatment for children hospitalised with bronchiolitis is supportive, including oxygen supplementation, respiratory support, and fluid therapy. Up to half of infants hospitalised with bronchiolitis require non-oral fluid therapy due to dehydration or concerns related to the safety of oral feeding. The two main modalities used for non-oral fluid therapy are parenteral (intravenous (IV)) and enteral tube (nasogastric (NG) or orogastric (OG)). However, it is not known which mode is optimal in young children.

OBJECTIVES

To systematically review randomised clinical trials (RCTs) of the effectiveness and safety of parenteral and enteral tube fluid therapy for children under two years of age hospitalised with bronchiolitis.

SEARCH METHODS

We conducted a search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, Web of Science, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 8 March 2021. We handsearched conference proceedings, conducted forward and backward searching of citation lists of relevant articles, and contacted experts.

SELECTION CRITERIA

We included RCTs and quasi-RCTs of children aged up to two years admitted to hospital with a clinical diagnosis of bronchiolitis who required fluid therapy. The trials compared enteral tube fluid therapy with parenteral fluid therapy. The primary outcome was difference in length of hospital stay in hours after each non-oral fluid therapy modality. As actual time of discharge can be impacted by various factors, we also assessed theoretical length of stay (i.e. time when a patient is safe for discharge). We assessed several secondary outcomes.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.  MAIN RESULTS: The searches yielded 615 unique records, of which four articles underwent full-text screening. We included two trials (810 children). Oakley 2013 was an open, non-blinded RCT of infants aged two to 12 months admitted to hospitals in Australia and New Zealand with a clinical diagnosis of bronchiolitis during three bronchiolitis seasons. The trial enrolled 759 children, of which 381 were randomised to NG tube therapy and 378 to IV therapy. Risk of bias was low in most domains. Kugelman 2013 was an open, non-blinded RCT that enrolled infants aged less than six months with a clinical diagnosis of "moderate bronchiolitis" at a single hospital in Israel. The study enrolled 51 infants, of which 31 were assigned to NG or OG tube therapy and 20 to IV therapy. Risk of bias was unclear in most domains. The application of enteral tube fluid therapy compared to IV fluid therapy probably makes little to no difference for actual length of hospital stay (mean difference (MD) 6.8 hours, 95% confidence interval (CI) -4.7 to 18.4 hours; 2 studies, 810 children, moderate certainty evidence). There was also little to no difference for theoretical length of stay (MD 4.4 hours, 95% CI -3.6 to 12.4 hours; 2 studies, 810 children, moderate certainty evidence). For the secondary outcomes, enteral tube fluid therapy probably makes little to no difference for time to resume full oral feeding compared to IV fluid therapy (MD 2.8 hours, 95% CI -3.6 to 9.2 hours; 2 studies, 810 children, moderate certainty evidence). The use of enteral tube for fluid therapy probably results in a large increase in the success of insertion of fluid modality at first attempt (risk ratio (RR) 1.52, 95% CI 1.36 to 1.69; 1 study, 617 children, moderate certainty evidence), and probably largely reduces the chances of change in fluid therapy modality (RR 0.52, 95% CI 0.38 to 0.71; 1 study, 759 children, moderate certainty evidence) compared to IV fluid.  Oakley 2013 reported 47 local complication events after discharge in the IV fluid group compared to 30 events in the NG tube group. They also evaluated parental satisfaction, which was high with both modalities. Enteral tube fluid therapy makes little to no difference to the duration of oxygen supplementation (MD 2.2 hours, 95% CI -5.0 to 9.5 hours; 2 studies, 810 children, moderate certainty evidence). Compared with the IV fluid therapy group, there was a 17% relative reduction in the number of intensive care unit admissions (RR 0.83, 95% CI 0.47 to 1.46; 1 study, 759 children, moderate certainty evidence) and a 19% relative reduction in number of readmissions to hospital (RR 0.81, 95% CI 0.33 to 2.04; 1 study, 678 children, moderate certainty evidence) in the enteral tube fluid therapy group. Adverse events were uncommon in both trials, with likely little to no differences between groups.

AUTHORS' CONCLUSIONS

Based on two RCTs, enteral tube feeding likely results in little to no difference in length of hospital stay compared with the IV fluid group. However, enteral tube fluid therapy likely results in a large increase in the success of insertion of fluid modality at first attempt, and a large reduction in change in modality of fluid therapy. It also probably reduces local complications compared to the IV fluid group. Despite bronchiolitis being one of the most prevalent childhood conditions, we identified only two studies with under 1000 participants in total, which highlights the need for multicentre trials. Future studies should explore type of fluid administered, parent-reported outcomes and preferences, and the role of shared decision-making.

Corticosteroids for periorbital and orbital cellulitis

BACKGROUND

Periorbital and orbital cellulitis are infections of the tissue anterior and posterior to the orbital septum, respectively, and can be difficult to differentiate clinically. Periorbital cellulitis can also progress to become orbital cellulitis. Orbital cellulitis has a relatively high incidence in children and adults, and potentially serious consequences including vision loss, meningitis, and death. Complications occur in part due to inflammatory swelling from the infection creating a compartment syndrome within the bony orbit, leading to elevated ocular pressure and compression of vasculature and the optic nerve. Corticosteroids are used in other infections to reduce this inflammation and edema, but they can lead to immune suppression and worsening infection.

OBJECTIVES

To assess the effectiveness and safety of adjunctive corticosteroids for periorbital and orbital cellulitis, and to assess their effectiveness and safety in children and in adults separately.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2020, Issue 3); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 2 March 2020.

SELECTION CRITERIA

We included studies of participants diagnosed with periorbital or orbital cellulitis. We excluded studies that focused exclusively on participants who were undergoing elective endoscopic surgery, including management of infections postsurgery as well as studies conducted solely on trauma patients. Randomized and quasi-randomized controlled trials were eligible for inclusion. Any study that administered corticosteroids was eligible regardless of type of steroid, route of administration, length of therapy, or timing of treatment. Comparators could include placebo, another corticosteroid, no treatment control, or another intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane.

MAIN RESULTS

The search yielded 7998 records, of which 13 were selected for full-text screening. We identified one trial for inclusion. No other eligible ongoing or completed trials were identified. The included study compared the use of corticosteroids in addition to antibiotics to the use of antibiotics alone for the treatment of orbital cellulitis. The study included a total of 21 participants aged 10 years and older, of which 14 participants were randomized to corticosteroids and antibiotics and 7 participants to antibiotics alone. Participants randomized to corticosteroids and antibiotics received adjunctive corticosteroids after initial antibiotic response (mean 5.13 days), at an initial dose of 1.5 mg/kg for three days followed by 1 mg/kg for another three days before being tapered over a one- to two-week period. We assessed the included study as having an unclear risk of bias for allocation concealment, masking (blinding), selective outcome reporting, and other sources of bias. Risk of bias from sequence generation and incomplete outcome data were low. The certainty of evidence for all outcomes was very low, downgraded for risk of bias (-1) and imprecision (-2). Length of hospital stay was compared between the group receiving antibiotics alone compared to the group receiving antibiotics and corticosteroids (mean difference (MD) 4.30, 95% confidence interval (CI) -0.48 to 9.08; 21 participants). There was no observed difference in duration of antibiotics between treatment groups (MD 3.00, 95% CI -0.48 to 6.48; 21 participants). Likewise, preservation of visual acuity at 12 weeks of follow-up between group was also assessed (RR 1.00, 95% CI 0.82 to 1.22; 21 participants). Pain scores were compared between groups on day 3 (MD -0.20, 95% CI -1.02 to 0.62; 22 eyes) along with the need for surgical intervention (RR 1.00, 95% CI 0.11 to 9.23; 21 participants). Exposure keratopathy was reported in five participants who received corticosteroids and antibiotics and three participants who received antibiotic alone (RR 1.20, 95% CI 0.40 to 3.63; 21 participants). No major complications of orbital cellulitis were seen in either the intervention or the control group. No side effects of corticosteroids were reported, although it is unclear which side effects were assessed.

AUTHORS' CONCLUSIONS

There is insufficient evidence to draw conclusions about the use of corticosteroids in the treatment of periorbital and orbital cellulitis. Since there is significant variation in how corticosteroids are used in clinical practice, additional high-quality evidence from randomized controlled trials is needed to inform decision making. Future studies should explore the effects of corticosteroids in children and adults separately, and evaluate different dosing and timing of corticosteroid therapy.

Identification of Preschool Children with Mental Health Problems in Primary Care: Systematic Review and Meta-analysis

OBJECTIVE

Primary care practitioners determine access to care for many preschool children with mental health (MH) problems. This study examined rates of mental health (MH) problem identification in preschoolers within primary healthcare settings, related service use, and MH status at follow-up. The findings may inform evidence-based policy and practice development for preschool MH.

METHOD

For this systematic review, MEDLINE®, EMBASE®, PsycInfo®, and ERIC ® were searched from inception to March 7, 2018 for reports in which a screening measure was used to identify MH problems in children aged 24-72 months, seen in primary and community health care settings. Meta-analyses, using random effects models to provide pooled estimates, were used when three or more studies examined identification rates. Findings on service use and persistence of disorders are summarized.

RESULTS

Thirty-five publications representing 21 studies met the inclusion criteria. MH problems were identified in 17.6% of preschoolers (95% Confidence Interval (CI): 11.1-24.1), Q = 4.9, p > 0.1 by primary/community healthcare practitioners. Psychiatric diagnoses were identified in 18.4% of preschoolers (95% CI: 12.3 - 24.4), Q= 1.6, p > 0.1. Based on three studies, parents of 67-72% of identified children received advice and 26-42% received specialist referrals. In the subset of studies examining persistence of MH disorders, 25-67% of identified children had MH disorders after one to three years.

CONCLUSION

While the identification rate by primary/community practitioners is similar to the diagnostic rate, these may not consistently be the same children. Substantial variability in management and outcomes indicate need for more rigorous evaluation of primary care services for this population.

Comparing two asthma diagnoses using a prospective cohort of young children

IntroductionAsthma is the most common chronic illness of childhood and places a large burden on the health care system. Asthma prevalence is commonly measured in national surveys by questionnaire. In Ontario, the Ontario Asthma Surveillance Information System (OASIS) developed a validated health claims diagnosis algorithm using health administrative data. Objectives and ApproachThe primary objective of this study was to measure the agreement between the health claims diagnosis algorithm (OASIS diagnosis algorithm) and questionnaire diagnosis (TARGet Kids! diagnosis) of asthma in children younger than 6 years of age. Secondary objectives were to identify concordant and discordant pairs, and to identify factors associated with disagreement. A comparison study including 3368 children participating in the TARGet Kids! practice based research network between 2008 and 2013 in Toronto, Canada. OASIS diagnosis algorithm and TARGet Kids! diagnosis asthma cases were compared using kappa statistic, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). ResultsPrevalence of asthma was estimated to be 15% by the OASIS diagnosis algorithm and 7% by TARGet Kids! diagnosis. The Kappa statistic was 0.47 (95% CI: 0.42 – 0.51), sensitivity 82\%, specificity 90%, PPV 38% and NPV 98% for OASIS diagnosis algorithm using TARGet Kids! diagnosis as the criterion standard. There were 3011 concordant pairs (2820 true negatives and 191 true positives) and 357 discordant pairs (315 false positives and 42 false negatives). Statistically significant factors associated with false positives included: male sex, higher zBMI and history of allergy. No statistically significant factors associated with false negatives were identified. Conclusion/ImplicationsOASIS diagnosis algorithm had high sensitivity, specificity, and NPV but low PPV relative to TARGet Kids! diagnosis of asthma. Although, the OASIS diagnosis may identify more asthma cases in young children, its diagnostic properties are similar in older children and it may be a useful tool for longitudinal asthma surveillance.

25-hydroxyvitamin D and health service utilization for asthma in early childhood

IntroductionAsthma is the most common chronic illness of childhood and a common reason for hospital admission. Studies suggest that low vitamin D levels may be associated with health service utilization (HSU) for childhood asthma. Objectives and ApproachThe primary objective was to determine if vitamin D serum levels in early childhood were associated with HSU for asthma including: a) total HSU, b) hospital admissions, c) emergency department visits and d) outpatient sick visits. Secondary objectives were to determine whether vitamin D supplementation in pregnancy or childhood were associated with HSU for asthma. Prospective cohort study of children participating in the TARGet Kids! practice based research network. HSU was determined by linking each child's provincial health insurance number to health administrative databases. Multivariable quasi Poisson and logistic regression were used to evaluate the associations. Results2926 healthy children ages 0-6 years had 25-hydroxyvitamin D data available and were included in the primary analysis. Mean (IQR) 25-hydroxyvitmain D level was 84 nmol/L (65-98 nmol/L), 218 and 1267 children had 25-hydroxyvitamin D levels <50 nmol/L and <75 nmol/L, respectively. In the adjusted models, there were no associations between 25-hydroxyvitamin D (continuously or dichotomized at 50 and 75 nmol/L), vitamin D supplementation in pregnancy or childhood and HSU for asthma. Conclusion/ImplicationsHigher vitamin D blood values do not appear to be associated with HSU for asthma in this population of healthy urban children.

Xylitol for the prevention of acute otitis media episodes in children aged 2-4 years: protocol for a pragmatic randomised controlled trial

INTRODUCTION

Xylitol (or 'birch sugar') is a naturally occurring sugar with antibacterial properties that has been used as a natural non-sugar sweetener in chewing gums, confectionery, toothpaste and medicines. In this preventative randomised trial, xylitol will be tested for the prevention of acute otitis media (AOM), a common and costly condition in young children. The primary outcome will be the incidence of AOM. Secondary outcomes will include upper respiratory tract infections (URTIs) and dental caries.

METHODS AND ANALYSIS

This study will be a pragmatic, blinded (participant and parents, practitioners and analyst), two-armed superiority, placebo-controlled randomised trial with 1:1 allocation, stratified by clinical site. The trial will be conducted in the 11 primary care group practices participating in the TARGet Kids! research network in Canada. Eligible participants between the ages of 2-4 years will be randomly assigned to the intervention arm of regular xylitol syrup use or the control arm of regular sorbitol use for 6 months. We expect to recruit 236 participants, per treatment arm, to detect a 20% relative risk reduction in AOM episodes. AOM will be identified through chart review. The secondary outcomes of URTIs and dental caries will be identified through monthly phone calls with specified questions.

ETHICS AND DISSEMINATION

Ethics approval from the Research Ethics Boards at the Hospital for Sick Children and St. Michael's Hospital has been obtained for this study and also for the TARGet Kids! research network. Results will be submitted for publication to a peer-reviewed journal and will be discussed with decision makers.

TRIAL REGISTRATION NUMBER

NCT03055091; Pre-results.

ACCELERATED GROWTH IN EARLY CHILDHOOD IS ASSOCIATED WITH INCREASED SYSTOLIC AND DIASTOLIC BLOOD PRESSURE

BACKGROUND

Maternal obesity, low birthweight, and accelerated growth have been shown to be associated with elevated blood pressure in children. However, it is unknown which growth periods are associated with blood pressure, and whether birthweight or maternal obesity modify the relationship between growth and blood pressure in early childhood.

OBJECTIVES

We examined the relationship between age- and sex-standardized body mass index (zBMI) growth trajectories with longitudinal measures of systolic (SBP) and diastolic (DBP) blood pressure in early childhood.

DESIGN/METHODS

We collected repeated measures of zBMI and blood pressure in 2502 children participating in the TARGet Kids! cohort. In stage 1 we used linear spline multilevel models to estimate each child’s zBMI at birth and zBMI growth trajectories in early infancy (0–3 m), late infancy (3–18 m) and toddler years (18–36 m). In stage 2 we used generalized estimating equations to examine the relationship between zBMI at birth and zBMI growth with repeated measures of SBP and DBP from 3 to 6 years of age. We tested for effect modification by birthweight and maternal obesity status by inclusion of interaction terms in each growth period.

RESULTS

After adjusting for confounders and prior growth, a 1 standard deviation unit increase in zBMI growth per month in early infancy (β=0.59; 95% CI 0.32,0.87) and late infancy (β=0.73; 95% CI 0.44,1.01), were associated with higher SBP. Growth in the toddler years was not significantly associated with SBP (p=0.08). Similar but smaller associations were observed for zBMI growth and DBP in early (β=0.29; 95% CI 0.04, 0.53) and late infancy (β=0.42; 95% CI 0.18, 0.66). Birthweight status modified (p=0.004) the relationship between zBMI growth and SBP during late infancy, with the strongest positive association observed in the low birthweight group. During toddler years, birthweight status modified the relationship between zBMI growth with SBP (p=0.03) and DBP (p=0.04), with the strongest positive association observed in the low birthweight group, followed by the high birthweight group. Maternal obesity status modified (p= 0.03) the relationship between zBMI growth with DBP in late infancy, with a stronger association observed among children of mothers with obesity.

CONCLUSION

Accelerated growth in early and late infancy are associated with increased blood pressure in early childhood. Growth during late infancy and toddler years may impact blood pressure differently in children born with high and low birthweights and high maternal BMI, suggesting prospective windows and risk groups to target interventions.

EVALUATING THE PREDICTIVE VALIDITY OF THE NIPISSING DISTRICT DEVELOPMENTAL SCREEN IN PRIMARY CARE SETTINGS AT THE 18-MONTH HEALTH SUPERVISION VISIT

BACKGROUND

The Canadian Paediatric Society (CPS) recommends that every Canadian physician caring for young children provide an enhanced 18-month well-baby visit including the use of a developmental screening tool, such as the Nipissing District Developmental Screen (NDDS). The Province of Ontario implemented an enhanced 18-month well-baby visit specifically emphasizing the NDDS, which is now widely used in Ontario primary care. However, the diagnostic accuracy of the NDDS in identifying early developmental delays in real-world clinical settings is unknown.

OBJECTIVES

To assess the predictive validity of the NDDS in primary care for identifying developmental delay and prompting a specialist referral at the 18-month health supervision visit.

DESIGN/METHODS

This was a prospective longitudinal cohort study enrolling healthy children from primary care practices. Parents completed the 18-month NDDS during their child’s scheduled health supervision visit between January 2012 and February 2015. Using a standardized data collection form, research personnel abstracted data from the child’s health records regarding the child’s developmental outcomes following the 18-month assessment. Data collected included confirmed diagnoses of a development delay, specialist referrals, family history, and interventions. Research personnel were blind to the results of the NDDS. We assessed the diagnostic test properties of the NDDS with a confirmed diagnosis of developmental delay as the criterion measure. The specificity, sensitivity, positive predictive value, and negative predictive value were calculated, with 95% confidence intervals.

RESULTS

We included 255 children with a mean age of 18.5 months (range, 17.5–20.6) and 139 (55%) were male. 102 (40%) screened positive (1+ flag result on their NDDS). A total of 48 (19%) children were referred, and 23 (9%) had a confirmed diagnosis of a developmental delay (speech and language: 14; gross motor: 4; autism spectrum disorder: 3; global developmental delay: 1; developmental delay: 1). The sensitivity was 74% (95% CI: 52–90%), specificity was 63% (95% CI: 57–70%), positive predictive value was 17% (95% CI:10–25%), and the negative predictive value was 96% (95% CI: 92–99%).

CONCLUSION

For developmental screening tools, sensitivity between 70%-80% and specificity of 80% have been suggested. The NDDS has moderate sensitivity and specificity in identifying developmental delay at the 18-month health supervision visit. The 1+NDDS flag cut-point may lead to overdiagnosis with more children with typical development being referred, leading to longer wait times for specialist referrals among children in need. Future work includes investigating the diagnostic accuracy of combining the NDDS with other screening tools.

DOES BREASTFEEDING DURATION INFLUENCE FAMILY FOOD INSECURITY?

BACKGROUND

Across all demographics, families without consistent access to adequate food place children at health risk. Consequences may persist beyond early life into adulthood. Public policy positions breastfeeding, the ideal nutrition for infants, as an important solution to reducing family food insecurity (FFI). However, few studies have investigated the association between breastfeeding duration and FFI.

OBJECTIVES

To evaluate the association between total breastfeeding duration and FFI in Canadian urban children.

DESIGN/METHODS

A cross-sectional study was conducted of children aged 0–2 years, from a practice-based child research network. Total breastfeeding duration was collected from parent-reported questionnaires. FFI was measured using 2-item food insecurity and validated 1-item NutriSTEP screens. Multivariable regression analysis was performed adjusting for pre-specified covariates.

RESULTS

Among 3838 children, the mean total breastfeeding duration was 10.6 months (SD=6.7). Families with food insecurity (14.7%) had increased odds of younger mothers, more males and older and more children. In adjusted model, breastfeeding duration was not associated with FFI (OR 0.99; 95% CI 0.98, 1.01). Low-income families were 9 times more likely to be family food insecure than high-income families (p=0.00).

CONCLUSION

Contrary to public policy, our study found no association between breastfeeding and family food insecurity (FFI). However, other factors may predominate, in particular family income and structure. Given the detrimental impact of FFI, further research is needed to understand the role of infant feeding practices within the larger political, policy and cultural framework.

Difficulty buying food, BMI, and eating habits in young children

OBJECTIVES

To determine whether parent report of difficulty buying food was associated with child body mass index (BMI) z-score or with eating habits in young children.

METHODS

This was a cross-sectional study in primary care offices in Toronto, Ontario. Subjects were children aged 1-5 years and their caregivers, recruited through the TARGet Kids! Research Network from July 2008 to August 2011. Regression models were developed to test the association between parent report of difficulty buying food because of cost and the following outcomes: child BMI z-score, parent's report of child's intake of fruit and vegetables, fruit juice and sweetened beverages, and fast food. Confounders included child's age, sex, birth weight, maternal BMI, education, ethnicity, immigration status, and neighbourhood income.

RESULTS

The study sample consisted of 3333 children. Data on difficulty buying food were available for 3099 children, and 431 of these (13.9%) were from households reporting difficulty buying food. There was no association with child BMI z-score (p = 0.86). Children from households reporting difficulty buying food (compared with never having difficulty buying food) had increased odds of consuming three or fewer servings of fruits and vegetables per day (odds ratio [OR]: 1.31, 95% confidence interval [CI]: 1.03-1.69), more than one serving of fruit juice/sweetened beverage per day (OR: 1.60, 95% CI: 1.28-2.00), and, among children 1-2 years old, one or more servings of fast food per week (OR: 2.91, 95% CI: 1.67-5.08).

CONCLUSION

Parental report of difficulty buying food is associated with less optimal eating habits in children but not with BMI z-score.

The impact of daycare attendance on outdoor free play in young children

Background

Outdoor free play is important for healthy growth and development in early childhood. Recent studies suggest that the majority of time spent in daycare is sedentary. The objective of this study was to determine whether there was an association between daycare attendance and parent-reported outdoor free play.

Methods

Healthy children aged 1-5 years recruited to The Applied Research Group for Kids! (TARGet Kids!), a primary care research network, were included. Parents reported daycare use, outdoor free play and potential confounding variables. Multivariable linear regression was used to determine the association between daycare attendance and outdoor free play, adjusted for age, sex, maternal ethnicity, maternal education, neighborhood income and season.

Results

There were 2810 children included in this study. Children aged 1 to <3 years (n = 1388) and ≥3 to 5 years (n = 1284) who attended daycare had 14.70 min less (95% CI -20.52, -8.87; P < 0.01) and 9.44 min less (95% CI -13.67, -5.20; P < 0.01) per day of outdoor free play compared with children who did not attend daycare, respectively.

Conclusions

Children who spend more time in daycare have less parent-reported outdoor free play. Parents may be relying on daycare to provide opportunity for outdoor free play and interventions to promote increased active play opportunities outside of daycare are needed.

International Variation in Asthma and Bronchiolitis Guidelines

BACKGROUND AND OBJECTIVES

Guideline recommendations for the same clinical condition may vary. The purpose of this study was to determine the degree of agreement among comparable asthma and bronchiolitis treatment recommendations from guidelines.

METHODS

National and international guidelines were searched by using guideline databases (eg, National Guidelines Clearinghouse: December 16-17, 2014, and January 9, 2015). Guideline recommendations were categorized as (1) recommend, (2) optionally recommend, (3) abstain from recommending, (4) recommend against a treatment, and (5) not addressed by the guideline. The degree of agreement between recommendations was evaluated by using an unweighted and weighted κ score. Pairwise comparisons of the guidelines were evaluated similarly.

RESULTS

There were 7 guidelines for asthma and 4 guidelines for bronchiolitis. For asthma, there were 166 recommendation topics, with 69 recommendation topics given in ≥2 guidelines. For bronchiolitis, there were 46 recommendation topics, with 21 recommendation topics provided in ≥2 guidelines. The overall κ for asthma was 0.03, both unweighted (95% confidence interval [CI]: -0.01 to 0.07) and weighted (95% CI: -0.01 to 0.10); for bronchiolitis, it was 0.32 unweighted (95% CI: 0.16 to 0.52) and 0.15 weighted (95% CI: -0.01 to 0.5).

CONCLUSIONS

Less agreement was found in national and international guidelines for asthma than for bronchiolitis. Additional studies are needed to determine if differences are based on patient preferences and values and economic considerations or if other recommendation-level, guideline-level, and condition-level factors are driving these differences.

Mosaic Neurofibromatosis Type 1 in Children: A Single-Institution Experience

BACKGROUND

Neurofibromatosis type 1 (NF1) is a neurocutaneous disorder caused by loss-of-function mutation in the NF1 gene. Segmental or mosaic NF1 (MNF) is an uncommon presentation of the NF1 result of postzygotic mutations that present with subtle localised clinical findings.

OBJECTIVES

Our study's objectives were to describe the clinical characteristics of children with MNF.

METHODS

We conducted a cross-sectional study of children diagnosed with MNF at the Hospital for Sick Children in Toronto, Canada, from January 1992 to September 2012. Data were abstracted from health records and analysed using a standardised data collection form approved by our hospital Research Ethics Board.

RESULTS

We identified 60 patients with MNF; 32 of 60 (53.3%) were female. Mean ± SD age at first assessment was 10.6 ± 4.6 years. The most common initial physical manifestation in 39 of 60 (65.0%) patients was localised pigmentary changes only, followed by plexiform neurofibromas only in 10 of 60 (16.7%) and neurofibromas only in 9 of 60 (15.0%). Unilateral findings were seen in 46 of 60 (76.7%) patients. Most common associations identified included learning disabilities (7/60; 12%) and bony abnormalities (6/60; 10.0%).

CONCLUSIONS

MNF is an underrecognised condition with potential implications for patients. Children mostly present with pigmentary anomalies only. Most patients do not develop associated findings or complications before adulthood, but long-term follow-up will help determine outcomes and possible associations. Recognition and confirmation of the diagnosis is important to provide follow-up and genetic counselling to patients.

Diagnostic accuracy of developmental screening in primary care at the 18-month health supervision visit: a cross-sectional study

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.

The Relationship between Milk Fat Content, Vitamin D and Adiposity in Early Childhood

BACKGROUND: Fortified cow’s milk is the main dietary source of vitamin D and an important source of dietary fat for North American children. Current guidelines recommend reduced milk fat consumption to reduce childhood obesity, yet the relationship between lower milk fat, vitamin D stores and adiposity is unclear.

OBJECTIVES: The objective of this study was to determine the association between percent fat content of milk and both zBMI and 25-hydroxyvi-tamin D; secondly, to explore if volume of milk consumed modified this relationship.

DESIGN/METHODS: A cross-sectional study of healthy urban children 12-72 months of age was conducted. Bivariate multiple linear regression was used to test the association between percent milk fat content and child 25-hydroxyvitamin D and zBMI concurrently. The interaction between volume of milk consumed and percent milk fat content was examined to explore how milk volume might modify these relationships.

RESULTS: 2745 children were included in the analysis. Percent fat content of milk was positively associated with 25-hydroxyvitamin D (p=0.006), and negatively associated with zBMI (p&lt;0.0001). Children who drank homogenized milk (3.25% fat) had 6.6 nmol/L (95% CI 5.49 to 7.71) higher median 25(OH)D concentration and 0.72 lower (95% CI 0.68 to 0.76) zBMI score than children who drank skim milk (0.1% fat). Volume of milk consumed potentiated the effect of percent fat content of milk on 25-hydroxyvitamin D (p=0.003) but not on zBMI (p=0.77). Children who drank 1 cup of homogenized milk each day had a similar 25-hydroxyvita-min D as children who drank 2.85 cups (95% CI 2.71 to 2.99) of skim milk, but had zBMI score 0.78 (95% CI 0.63, 0.93) units lower.

CONCLUSION: Homogenized milk may be more appropriate than reduced fat milk in maximizing serum 25-hydroxyvitamin D and minimizing adiposity in early childhood. Current guidelines for reduced milk fat consumption in childhood may require further study to achieve desired outcomes.

How Well Does the Nipissing District Developmental Screen (NDDS) Identify Communication Problems in Infants?

BACKGROUND: Communication problems are often the first presenting problem in infants with developmental disabilities. With early detection, intervention can start. The 18-month Nipissing District Developmental Screen (NDDS) was created as a developmental checklist for use in primary care. The Infant Toddler Checklist (ITC) is a validated questionnaire for detecting communication problems. Our objective was to examine how well the 18-month NDDS identifies communication problems. We therefore assessed the convergent validity of the 18-month NDDS with the ITC as a gold standard.

OBJECTIVES: To examine how well the 18-month NDDS identifies communication problems. To compare parents’ answers to a similar question, “How many different words does your child use?”, on both checklists.

DESIGN/METHODS: Healthy children (n = 348, 55% male, mean age 18.6 months, SD 0.7) were recruited during scheduled health supervision visits. Parents completed both the 18-months NDDS and ITC. We assessed the convergent validity of the 18-month NDDS with the ITC as a gold standard. Correlation (Spearman) and the level of agreement (Cohen’s kappa, sensitivity, specificity) were calculated. For our secondary outcome, we compared the percentage of agreement between the answers to the same question on both instruments.

RESULTS: On the NDDS, 138 (39.7%) children had “one or more flags” (+1 NDDS) and 54 (15.8%) children had “two or more flags” (+2 NDDS). 13 (3.7%) infants had a concern on the total ITC score, 31 (8.9%) a speech-, 9 (2.6%) a social -, and 14 (4.0%) a symbolic concern.The +2 NDDS had a medium correlation (Spearman’s rho 0.42) and a fair agreement (Cohen’s kappa 0.32) with the ITC. Sensitivity and specificity of the NDDS using the +1 and + 2 flag cut-offs in detecting concerns compared with the ITC are shown in the table.The similar question about number of words spoken by 18-month old infants revealed agreement between the NDDS and ITC; 24.4% versus 30.8% of the 18-month old infants did not speak 20 words or more respectively.

CONCLUSION: Infants with a severe overall communication delay were identified with the 18-months NDDS. The low sensitivity of the 2+ NDDS flag in detecting speech and social concerns suggests that infants who could benefit from early interventions may not be identified.The low specificity of the 1+ NDDS flag may cause unnecessary concerns for parents.For the early identification of all levels of communicationdelays, we recommend using a standardized questionnaire like the ITC.

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Screening for Risk of Developmental Delay in a primary care setting using the Nippising District Developmental Screen

BACKGROUND: Early growth and development in the first five years of life is strongly associated with health outcomes. The Nipissing District Developmental Screen (NDDS) is a free parent-reported screening tool recommended by the Canadian Pediatric Society as one of the tools for developmental screening in children

OBJECTIVES: To determine the prevalence of a positive screen for risk of developmental delay in a cohort of healthy children at 18-months and 5 years. To identify risk factors (child, socio-demo-graphic and home environment) associated with a positive screen for risk of developmental delay.

DESIGN/METHODS: A cross-sectional study of healthy Canadian children attending 18-months and 5 year well-child visits between June 2008 and February 2015 was conducted through the TARGet Kids! practice-based research network. Multivariable logistic regression was used to identify risk factors associated with a positive screen for developmental delay. Risk factors of development delay identified from literature were:, male sex, low birth weight, low income, low maternal education, maternal unemployment, non-industrialized immigrant status, single parent family, only child and older maternal age.

RESULTS: 1086 children (53% male) at 18 months and 575 children (51% male) at 5 years were included in the final analysis. At 18 months, 341 (31.4%) of children (95% CI, 28.7% - 34.3%) and at 5 years 166 (28.9%) (95% CI, 25.2% -32.8%) were screen positive base on 1+ flag NDDS. At 18 months, children with a low birthweight (OR=1.66; 95% CI 1.22-2.28), with a mother with low education (OR=1.75; 95% CI 1.07-2.85), and those from non-industrialized immigrant families (OR=1.85; 95% CI 1.37-2.49) were associated with an increased odds of a positive screen for developmental delay based on the 1+ NDDS flag. A female child (OR=0.74; 95% CI 0.57-0.96) and an only child (OR=0.76; 95% CI 0.57-0.99) were associated with a decreased odds of a positive screen for developmental delay. At 5 years, factors associated with a positive screen for developmental delay based on the 1+ NDDS flag were: low maternal education (OR 2.24; 95% CI 1.14-4.39) (children had 2.24 times greater odds of a positive screen for developmental delay) and older maternal age (OR 1.05; 95% CI 1.00-1.09) (every 1-year increase in maternal age, children had 1.05 times greater odds of a positive screen for developmental delay). A female child was associated with a decreased odds of a positive screen for developmental delay (OR=0.66; 95% CI 0.46-0.96) based on the 1+ NDDS flag.

CONCLUSION: In a population of healthy urban children the NDDS identified 30% at both 18 month and 5 years at risk for developmental delay. Risk factors for developmental delay were associated with a positive NDDS screen.

Hypertension screening and follow-up in children and adolescents in a Canadian primary care population sample: a retrospective cohort studystudy

BACKGROUND

Uncertainty exists about the need to screen for hypertension in children and adolescents. Information on current screening and follow-up rates in Canadian community practices is not available. There are no Canadian guidelines on the subject. We sought to identify current rates of pediatric hypertension screening and follow-up in Canada. In addition, we examined patient and provider characteristics associated with rates of blood pressure screening.

METHODS

We used electronic medical record data extracted on Apr. 1, 2013, from 79 family practices in Toronto. We identified children seen at least twice between the ages of 3 and 18 years, with at least 6 months between first and last encounter. We used Multivariate Poisson regression analysis to analyze variation in blood pressure measurement rates and associations with patient and physician factors.

RESULTS

We identified 5996 children (62% of 9667 in total) who had at least 1 blood pressure measurement recorded. Of these children, 14% had at least 1 abnormal blood pressure measurement, and of those children, only 5% had a follow-up measurement recorded within 6 months. After adjustment, increases in rates of blood pressure measurements were associated with greater number of encounters (rate ratio [RR] = 1.03, 95% confidence interval [CI] 1.02-1.04, p < 0.001), older age at first encounter (RR = 1.06, 95% CI 1.03-1.10, p = 0.002), and female sex (RR = 1.12, 95% CI 1.03-1.20, p = 0.006). Obesity or a recorded family history of hypertension were not associated with more blood pressure measurements. Female physicians recorded more blood pressure measurements than did male physicians (RR = 1.41, 95% CI 1.04-1.89, p = 0.02).

INTERPRETATION

This screening measure was frequently done and appeared to be incompletely followed up. Clear guidance is needed; guideline developers should consider reviewing this topic.

Mosaic Neurofibromatosis Type 1: A Systematic Review

Confusion is widespread regarding segmental or mosaic neurofibromatosis type 1 (MNF1). Physicians should use the same terms and be aware of its comorbidities and risks. The objective of the current study was to identify and synthesize data for cases of MNF1 published from 1977 to 2012 to better understand its significance and associations. After a literature search in PubMed, we reviewed all available relevant articles and abstracted and synthetized the relevant clinical data about manifestations, associated findings, family history and genetic testing. We identified 111 articles reporting 320 individuals. Most had pigmentary changes or neurofibromas only. Individuals with pigmentary changes alone were identified at a younger age. Seventy-six percent had localized MNF1 restricted to one segment; the remainder had generalized MNF1. Of 157 case reports, 29% had complications associated with NF1. In one large case series, 6.5% had offspring with complete NF1. The terms "segmental" and "type V" neurofibromatosis should be abandoned, and the correct term, mosaic NF1 (MNF1), should be used. All individuals with suspected MNF1 should have a complete physical examination, genetic testing of blood and skin, counseling, and health surveillance.

Probiotics for the prevention of pediatric antibiotic-associated diarrhea

BACKGROUND

Antibiotics are frequently prescribed in children. They alter the microbial balance within the gastrointestinal tract, commonly resulting in antibiotic-associated diarrhea (AAD). Probiotics may prevent AAD via restoration of the gut microflora.

OBJECTIVES

The primary objectives were to assess the efficacy and safety of probiotics (any specified strain or dose) used for the prevention of AAD in children.

SEARCH METHODS

MEDLINE, EMBASE, CENTRAL, CINAHL, AMED, and the Web of Science (inception to November 2014) were searched along with specialized registers including the Cochrane IBD/FBD review group, CISCOM (Centralized Information Service for Complementary Medicine), NHS Evidence, the International Bibliographic Information on Dietary Supplements as well as trial registries. Letters were sent to authors of included trials, nutraceutical and pharmaceutical companies, and experts in the field requesting additional information on ongoing or unpublished trials. Conference proceedings, dissertation abstracts, and reference lists from included and relevant articles were also searched.

SELECTION CRITERIA

Randomized, parallel, controlled trials in children (0 to 18 years) receiving antibiotics, that compare probiotics to placebo, active alternative prophylaxis, or no treatment and measure the incidence of diarrhea secondary to antibiotic use were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Study selection, data extraction as well as methodological quality assessment using the risk of bias instrument was conducted independently and in duplicate by two authors. Dichotomous data (incidence of diarrhea, adverse events) were combined using a pooled risk ratio (RR) or risk difference (RD), and continuous data (mean duration of diarrhea, mean daily stool frequency) as mean difference (MD), along with their corresponding 95% confidence interval (95% CI). For overall pooled results on the incidence of diarrhea, sensitivity analyses included available case versus extreme-plausible analyses and random- versus fixed-effect models. To explore possible explanations for heterogeneity, a priori subgroup analysis were conducted on probiotic strain, dose, definition of antibiotic-associated diarrhea, as well as risk of bias. We also conducted post hoc subgroup analyses by patient diagnosis, single versus multi-strain, industry sponsorship, and inpatient status. The overall quality of the evidence supporting the outcomes was evaluated using the GRADE criteria.

MAIN RESULTS

Twenty-three studies (3938 participants) met the inclusion criteria. Trials included treatment with either Bacillus spp., Bifidobacterium spp., Clostridium butyricum, Lactobacilli spp., Lactococcus spp., Leuconostoc cremoris, Saccharomyces spp., orStreptococcus spp., alone or in combination. Eleven studies used a single strain probiotic, four combined two probiotic strains, three combined three probiotic strains, one combined four probiotic strains, two combined seven probiotic strains, one included ten probiotic strains, and one study included two probiotic arms that used three and two strains respectively. The risk of bias was determined to be high or unclear in 13 studies and low in 10 studies. Available case (patients who did not complete the studies were not included in the analysis) results from 22/23 trials reporting on the incidence of diarrhea show a precise benefit from probiotics compared to active, placebo or no treatment control. The incidence of AAD in the probiotic group was 8% (163/1992) compared to 19% (364/1906) in the control group (RR 0.46, 95% CI 0.35 to 0.61; I(2) = 55%, 3898 participants). A GRADE analysis indicated that the overall quality of the evidence for this outcome was moderate. This benefit remained statistically significant in an extreme plausible (60% of children loss to follow-up in probiotic group and 20% loss to follow-up in the control group had diarrhea) sensitivity analysis, where the incidence of AAD in the probiotic group was 14% (330/2294) compared to 19% (426/2235) in the control group (RR 0.69; 95% CI 0.54 to 0.89; I(2) = 63%, 4529 participants). None of the 16 trials (n = 2455) that reported on adverse events documented any serious adverse events attributable to probiotics. Meta-analysis excluded all but an extremely small non-significant difference in adverse events between treatment and control (RD 0.00; 95% CI -0.01 to 0.01). The majority of adverse events were in placebo, standard care or no treatment group. Adverse events reported in the studies include rash, nausea, gas, flatulence, abdominal bloating, abdominal pain, vomiting, increased phlegm, chest pain, constipation, taste disturbance, and low appetite.

AUTHORS' CONCLUSIONS

Moderate quality evidence suggests a protective effect of probiotics in preventing AAD. Our pooled estimate suggests a precise (RR 0.46; 95% CI 0.35 to 0.61) probiotic effect with a NNT of 10. Among the various probiotics evaluated, Lactobacillus rhamnosus or Saccharomyces boulardii at 5 to 40 billion colony forming units/day may be appropriate given the modest NNT and the likelihood that adverse events are very rare. It is premature to draw conclusions about the efficacy and safety of other probiotic agents for pediatric AAD. Although no serious adverse events were observed among otherwise healthy children, serious adverse events have been observed in severely debilitated or immuno-compromised children with underlying risk factors including central venous catheter use and disorders associated with bacterial/fungal translocation. Until further research has been conducted, probiotic use should be avoided in pediatric populations at risk for adverse events. Future trials would benefit from a standard and valid outcomes to measure AAD.