Sociodemographic Factors and Trends in Bronchiolitis-Related Emergency Department Visit and Hospitalization Rates.

Importance: Bronchiolitis is the most common and most cumulatively expensive condition in pediatric hospital care. Few population-based studies have examined health inequalities in bronchiolitis outcomes over time. Objective: To examine trends in bronchiolitis-related emergency department (ED) visit and hospitalization rates by sociodemographic factors in a universally funded health care system. Design, Setting, and Participants: This repeated cross-sectional cohort study was performed from April 1, 2004, to March 31, 2022, using population-based health administrative data from children younger than 2 years in Ontario, Canada. Main Outcome and Measures: Bronchiolitis ED visit and hospitalization rates per 1000 person-years reported for the equity stratifiers of sex, residence location (rural vs urban), and material resources quintile. Trends in annual rates by equity stratifiers were analyzed using joinpoint regression and estimating the average annual percentage change (AAPC) with 95% CI and the absolute difference in AAPC with 95% CI from April 1, 2004, to March 31, 2020. Results: Of 2 921 573 children included in the study, 1 422 088 (48.7%) were female and 2 619 139 (89.6%) lived in an urban location. Emergency department visit and hospitalization rates were highest for boys, those with rural residence, and those with least material resources. There were no significant between-group absolute differences in the AAPC in ED visits per 1000 person-years by sex (female vs male; 0.22; 95% CI, -0.92 to 1.35; P = .71), residence (rural vs urban; -0.31; 95% CI -1.70 to 1.09; P = .67), or material resources (quintile 5 vs 1; -1.17; 95% CI, -2.57 to 0.22; P = .10). Similarly, there were no significant between-group absolute differences in the AAPC in hospitalizations per 1000 person-years by sex (female vs male; 0.53; 95% CI, -1.11 to 2.17; P = .53), residence (rural vs urban; -0.62; 95% CI, -2.63 to 1.40; P = .55), or material resources (quintile 5 vs 1; -0.93; 95% CI -3.80 to 1.93; P = .52). Conclusions and Relevance: In this population-based cohort study of children in a universally funded health care system, inequalities in bronchiolitis ED visit and hospitalization rates did not improve over time.

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.

Haemoglobin thresholds to define anaemia from age 6 months to 65 years: estimates from international data sources.

BACKGROUND: Detection of anaemia is crucial for clinical medicine and public health. Current WHO anaemia definitions are based on statistical thresholds (fifth centiles) set more than 50 years ago. We sought to establish evidence for the statistical haemoglobin thresholds for anaemia that can be applied globally and inform WHO and clinical guidelines. METHODS: In this analysis we identified international data sources from populations in the USA, England, Australia, China, the Netherlands, Canada, Ecuador, and Bangladesh with sufficient clinical and laboratory information collected between 1998 and 2020 to obtain a healthy reference sample. Individuals with clinical or biochemical evidence of a condition that could reduce haemoglobin concentrations were excluded. We estimated haemoglobin thresholds (ie, 5th centiles) for children aged 6-23 months, 24-59 months, 5-11 years, and 12-17 years, and adults aged 18-65 years (including during pregnancy) for individual datasets and pooled across data sources. We also collated findings from three large-scale genetic studies to summarise genetic variants affecting haemoglobin concentrations in different ancestral populations. FINDINGS: We identified eight data sources comprising 18 individual datasets that were eligible for inclusion in the analysis. In pooled analyses, the haemoglobin fifth centile was 104·4 g/L (90% CI 103·5-105·3) in 924 children aged 6-23 months, 110·2 g/L (109·5-110·9) in 1874 children aged 24-59 months, and 114·4 g/L (113·6-115·2) in 1839 children aged 5-11 years. Values diverged by sex in adolescents and adults. In pooled analyses, the fifth centile was 122·2 g/L (90% CI 121·3-123·1) in 1741 female adolescents aged 12-17 years and 128·2 g/L (126·4-130·0) in 1103 male adolescents aged 12-17 years. In pooled analyses of adults aged 18-65 years, the fifth centile was 119·7 g/L (90% CI 119·1-120·3) in 3640 non-pregnant females and 134·9 g/L (134·2-135·6) in 2377 males. Fifth centiles in pregnancy were 110·3 g/L (90% CI 109·5-111·0) in the first trimester (n=772) and 105·9 g/L (104·0-107·7) in the second trimester (n=111), with insufficient data for analysis in the third trimester. There were insufficient data for adults older than 65 years. We did not identify ancestry-specific high prevalence of non-clinically relevant genetic variants that influence haemoglobin concentrations. INTERPRETATION: Our results enable global harmonisation of clinical and public health haemoglobin thresholds for diagnosis of anaemia. Haemoglobin thresholds are similar between sexes until adolescence, after which males have higher thresholds than females. We did not find any evidence that thresholds should differ between people of differering ancestries. FUNDING: World Health Organization and the Bill & Melinda Gates Foundation.

Association of factors with childhood asthma and allergic diseases using latent class analysis.

We hypothesize that children characterized by deprived factors have poorer health outcomes. We aim to identify clustering of determinants and estimate risk of early childhood diseases. This 1993-2019 longitudinal cohort study combines three Canadian pediatric cohorts and their families. Mothers and children are clustered using latent class analysis (LCA) by 16 indicators in three domains (maternal and newborn; socioeconomic status [SES] and neighbourhood; environmental exposures). Hazard ratios (HR) of childhood asthma, allergic rhinitis (AR), and eczema are quantified with Cox proportional hazard (PH) regression. Rate ratios (RR) of children's health services use (HSU) are estimated with Poisson regression. Here we report the inclusion of 15,724 mother-child pairs; our LCA identifies four mother-clusters. Classes 1 and 2 mothers are older (30-40 s), non-immigrants with university education, living in high SES neighbourhoods; Class 2 mothers have poorer air quality and less greenspace. Classes 3 and 4 mothers are younger (20-30 s), likely an immigrant/refugee, with high school-to-college education, living in lower SES neighborhoods with poorer air quality and less greenspace. Children's outcomes differ by Class, in comparison to Class 1. Classes 3 and 4 children have higher risks of asthma (HR 1.24, 95% CI 1.11-1.37 and HR 1.39, 95% CI 1.22-1.59, respectively), and similar higher risks of AR and eczema. Children with AR in Class 3 have 20% higher all-cause physician visits (RR = 1.20, 95% CI 1.10-1.30) and those with eczema have 18% higher all-cause emergency department visits (RR = 1.18, 95% CI 1.09-1.28) and 14% higher all-cause physician visits (RR = 1.14, 95% CI 1.09-1.19). Multifactorial-LCA mother-clusters may characterize associations of children's health outcomes and care, adjusting for interrelationships.

Connecting families: a qualitative study examining the experiences of parenting young children under financial strain in Ontario, Canada.

BACKGROUND: There is little research investigating the subjective experiences of parenting young children while living in poverty and experiencing financial strain using qualitative methodologies. Therefore, the objective of this study was to employ a qualitative approach to provide a nuanced and balanced view on the topic of parenting young children under financial strain in the Canadian context. METHODS: We conducted a qualitative study using semi-structured interviews between July and August 2021 in Kingston, Ontario, Canada. Sixteen participants aged 20-39 self-identified as living under financial strain while parenting a child aged 2-5 years. A qualitative inductive thematic analysis was undertaken with a focus on describing the contents of the data. RESULTS: Four major themes emerged from the data: experience of being a parent, impact of financial strain on the family unit, impact of financial strain on the children, and impact of financial strain on the parent. Numerous deleterious physical, mental, and material impacts on the family unit and parent were identified, however parent-perceived impacts of financial strain on their children were minimal. Parents described striking levels of resourcefulness and resiliency in providing the necessities for their families, absorbing the most significant impacts of financial strain through the phenomenon of self-sacrifice. CONCLUSION: The impacts of financial strain on families with young children are far reaching. Further research into the impacts of self-sacrifice on parents experiencing financial strain are needed to better understand this issue, and to inform social programming and resources that could help alleviate the deleterious impacts of poverty on parent mental, social, and physical health.

Oxygen Saturation Targets in Infants Hospitalized With Bronchiolitis: A Multicenter Cohort Study.

OBJECTIVES: To examine 2 hospital oxygen saturation target policies and clinical outcomes in infants hospitalized with bronchiolitis. METHODS: This multicenter cohort study used data collected from a randomized clinical trial of infants aged 4 weeks to 24 months, hospitalized with bronchiolitis at children's and community hospitals from 2016 to 2019. We modeled the association between hospital oxygen saturation target policy, either 90% while awake and 88% while asleep (90%/88%) or 90% while awake and asleep (90%/90%), and clinical outcomes. RESULTS: A total of 162 infants were enrolled at 4 hospitals using a 90%/88% oxygen saturation target and 67 infants at 2 hospitals using a 90%/90% target policy. No significant differences between the 90%/88% group and 90%/90% groups were observed for time to discharge (adjusted hazard ratio, 0.83; 95% confidence interval [CI], 0.61-1.14; P = .25), initiation of supplemental oxygen (adjusted odds ratio [aOR], 0.98; 95% CI, 0.47-2.02; P = .95), time to discontinuation of supplemental oxygen (adjusted hazard ratio, 0.75; 95% CI, 0.44-1.27; P = .28), revisits (aOR, 1.38; 95% CI, 0.52-3.71; P = .52), and parent days missed from work (aOR, 2.41; 95% CI, 0.90-6.41; P = .08). Three infants in the 90%/88% group and none in the 90%/90% group were transferred to the ICU. CONCLUSIONS: Among infants hospitalized with bronchiolitis, clinical outcomes were similar between a hospital oxygen saturation target policy of 90% while awake and 88% while asleep compared with 90% while awake and asleep. These findings may inform the design of future trials of oxygen saturation targets in bronchiolitis hospital care.

Xylitol for the prevention of acute otitis media episodes in children aged 1-5 years: a randomised controlled trial.

OBJECTIVE: To investigate the regular use of xylitol, compared with sorbitol, to prevent acute otitis media (AOM), upper respiratory tract infections (URTIs) and dental caries. DESIGN: Blinded randomised controlled trial with a 6-month study period. SETTING: Enrolment took place at 11 primary care practices in Ontario, Canada. PATIENTS: Children aged 1-5 years who did not use xylitol or sorbitol at enrolment. INTERVENTIONS: Children were randomly assigned to use a placebo syrup with sorbitol or xylitol syrup two times per day for 6 months. MAIN OUTCOME MEASURES: Primary outcome was the number of clinician-diagnosed AOM episodes over 6 months. Secondary outcomes were caregiver-reported URTIs and dental caries. RESULTS: Among the 250 randomised children, the mean (SD) age was 38±14 months and there were 124 girls (50%). There were three clinician-diagnosed AOM episodes in the 125 placebo group participants and six in the 125 xylitol group participants (OR 2.04; 95% CI 0.43, 12.92; p=0.50). There was no difference in number of caregiver-reported URTI episodes (rate ratio (RR) 0.88; 95% CI 0.70, 1.11) between the placebo (4.2 per participant over 6 months; 95% CI 3.6, 5.0) and xylitol (3.7; 95% CI 3.2, 4.4) groups. Dental caries were reported for four participants in the placebo group and two in the xylitol group (OR 0.42; 95% CI 0.04, 3.05; p=0.42). In a post-hoc analysis of URTIs during the COVID-19 pandemic, the rate among the 59 participants receiving placebo was 2.3 per participant over 6 months (95% CI 1.8, 3.0) and for the 55 receiving xylitol, 1.3 over 6 months (95% CI 0.92, 1.82; RR 0.56; 95% CI 0.36, 0.87). The most common adverse event was diarrhoea (28% with placebo; 34% with xylitol). CONCLUSIONS: Regular use of xylitol did not prevent AOM, URTIs or dental caries in a trial with limited statistical power. A post-hoc analysis indicated that URTIs were less common with xylitol exposure during the COVID-19 pandemic, but this finding could be spurious. TRIAL REGISTRATION NUMBER: NCT03055091.

Hemoglobin Threshold for Blood Transfusion in Young Children Hospitalized with Iron Deficiency Anemia.

Current recommendations advise against blood transfusion in hemodynamically stable children with iron deficiency anemia. In an observational study of 125 children aged 6 through 36 months, hospitalized with iron deficiency anemia, we found that hemoglobin level predicted red blood cell transfusion (area under the curve 0.8862). A hemoglobin of 39 g/L had sensitivity 92% and specificity 72% for transfusion.

Association Between Family Income and Positive Developmental Screening Using the Infant Toddler Checklist at the 18-Month Health Supervision Visit.

OBJECTIVE: To examine the associations between several potential predictors (child biologic, social, and family factors) and a positive screen for developmental delay using the Infant Toddler Checklist (ITC) at the 18-month health supervision visit in primary care. METHODS: This was a cross-sectional study of healthy children attending an 18-month health supervision visit in primary care. Parents completed a standardized questionnaire, addressing child, social, and family characteristics, and the ITC. Logistic regression analyses were used to assess the associations between predictors and a positive ITC. RESULTS: Among 2188 participants (45.5% female; mean age, 18.2 months), 285 (13%) had a positive ITC and 1903 (87%) had a negative ITC. The aOR for a positive ITC for male compared with female sex was 2.15 (95% CI, 1.63-2.83; P < .001). The aOR for birthweight was 0.65 per 1 kg increase (95% CI, 0.53-0.80; P < .001). The aOR for a family income of <$40,000 compared with ≥$150,000 was 3.50 (95% CI, 2.22-5.53; P < .001), and the aOR for family income between $40,000-$79,999 compared with ≥$150,000 was 1.88 (95% CI, 1.26-2.80; P = .002). CONCLUSIONS: Screening positive on the ITC may identify children at risk for the double jeopardy of developmental delay and social disadvantage and allow clinicians to intervene through monitoring, referral, and resource navigation for both child development and social needs. TRIAL REGISTRATION: Clinicaltrials.gov (NCT01869530).

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.

Paediatric reference intervals and curves for haemoglobin and ferritin: protocol for a systematic review and meta-analysis.

INTRODUCTION: Reference intervals and reference curves provide clinicians with a point of reference when evaluating patients' laboratory test results. In practical applications, the 2.5th and 97.5th percentiles of healthy reference population are typically used as lower and upper reference limits. Guidelines outlining analytical and methodological steps involved in reference intervals and curves estimation are available and there have been large-scale world-wide initiatives to provide reference intervals and curves for children. However, there is a lack of synthesised evidence regarding the results of such initiatives in general, but specifically in iron-related biomarkers, ferritin (in serum and plasma) and haemoglobin. Objectives of this review are to identify studies that have produced reference intervals and curves for ferritin and haemoglobin in paediatric populations and to synthesise all available evidence. We also aim to quantify heterogeneity across reference intervals and curves and identify and elucidate sources of heterogeneity, including heterogeneity in the methods employed in their development. METHODS AND ANALYSIS: Using a comprehensive search strategy, we will identify eligible studies. Following electronic databases will be searched from inception: EMBASE, MEDLINE, SCOPUS and The Cochrane Library. We will also perform grey literature search to capture unpublished reference intervals and curves from healthy cohorts. Two researchers will independently screen retrieved citations against eligibility criteria in two stages, focusing first on titles and abstracts and then on full-text articles. Studies that provide reference intervals and curves for ferritin and haemoglobin for paediatric population will be eligible. Data extraction will include study characteristics, characteristics of reference population, methodological and analytical considerations and estimated reference intervals and curves. We will consider narrative synthesis and quantitative synthesis when appropriate. ETHICS AND DISSEMINATION: Ethical approval is not required as data from already published studies will be used. Results will be disseminated through peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42023399802.

Screening Accuracy of the Parent-Report Preschool Strengths and Difficulties Questionnaire in Primary Care.

OBJECTIVE: To evaluate the screening test accuracy and reliability of the parent-report preschool Strengths and Difficulties Questionnaire (P-SDQ) in primary care settings. METHODS: Children 24 to 48 months were recruited at scheduled primary care visits in Toronto, Canada. Parents completed the P-SDQ at baseline, 2, and 12 weeks. At 12 weeks, parents were invited to a semistructured diagnostic phone interview, the Preschool Age Psychiatric Assessment (PAPA). Criterion validity between baseline P-SDQ scores (Total Difficulties Score [TDS], internalizing and externalizing subscale) and Diagnostic and Statistical Manual, 5th edition diagnoses on PAPA was evaluated using area under the curve (AUC) and calculating screening test properties (sensitivity and specificity). Test-retest reliability at baseline and 2 weeks was evaluated using intraclass correlation coefficient. RESULTS: A total of 183 children were enrolled, mean age 39.3 (SD 7.4) months, 46.4% male, 120 (66%) completed P-SDQ at 2 weeks, 107 (58%) completed PAPA at 12 weeks. Of those with a PAPA, 26 (24%) had any psychiatric diagnosis, 17 (16%) had internalizing disorders and 4 (4%) had externalizing disorders. TDS identified any diagnosis with AUC = 0.67 (95% confidence intervals (CI): 0.55, 0.79); internalizing subscale identified internalizing disorders with AUC = 0.61 (95% CI: 0.47, 0.74); externalizing subscale identified externalizing disorders with AUC = 0.77 (95% CI: 0.60, 0.94). Sensitivity and specificity, and test-retest reliability were satisfactory for TDS and externalizing subscale, and less satisfactory for the internalizing subscale. CONCLUSIONS: The externalizing subscale has sufficient accuracy and reliability to identify children aged 2 to 4 years at risk for attention deficit/hyperactivity disorder and disruptive behavior disorders in primary 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.

Nasal Suctioning Therapy Among Infants With Bronchiolitis Discharged Home From the Emergency Department: A Randomized Clinical Trial.

Importance: Although nasal suctioning is the most frequently used supportive management for bronchiolitis, its benefit remains unknown. Objective: To evaluate the effectiveness of enhanced vs minimal nasal suctioning in treating infants with bronchiolitis after discharge from the emergency department (ED). Design, Setting, and Participants: This single-blind, parallel-group, randomized clinical trial was conducted from March 6, 2020, to December 15, 2022, at 4 tertiary-care Canadian pediatric EDs. Participants included otherwise healthy infants aged 1 to 11 months with a diagnosis of bronchiolitis who were discharged home from the ED. Interventions: Participants were randomized to minimal suctioning via bulb or enhanced suctioning via a battery-operated device before feeding for 72 hours. Main Outcomes and Measures: The primary outcome was additional resource use, a composite of unscheduled revisits for bronchiolitis or use of additional suctioning devices for feeding and/or breathing concerns. Secondary outcomes included health care utilization, feeding and sleeping adequacy, and satisfaction. Results: Of 884 screened patients, 352 were excluded for criteria, 79 declined participation, 81 were otherwise excluded, 372 were randomized (185 to the minimal suction group and 187 to the enhanced suction group), and 367 (median [IQR] age, 4 [2-6] months; 221 boys [60.2%]) completed the trial (184 in the minimal suction and 183 in the enhanced suction group). Additional resource use occurred for 68 of 184 minimal suction participants (37.0%) vs 48 of 183 enhanced suction participants (26.2%) (absolute risk difference, 0.11; 95% CI, 0.01 to 0.20; P = .03). Unscheduled revisits occurred for 47 of 184 minimal suction participants (25.5%) vs 40 of 183 enhanced suction participants (21.9%) (absolute risk difference, 0.04; 95% CI, -0.05 to 0.12; P = .46). A total of 33 of 184 parents in the minimal suction group (17.9%) used additional suctioning devices vs 11 of 183 parents in the enhanced suction group (6.0%) (absolute risk difference, 0.12; 95% CI, 0.05 to 0.19; P < .001). No significant between-group differences were observed for all bronchiolitis revisits (absolute risk difference, 0.07; 95% CI, -0.02 to 0.16; P = .15), ED revisits (absolute risk difference, 0.04; 95% CI, -0.03 to 0.12; P = .30), parental care satisfaction (absolute risk difference, -0.02; 95% CI, -0.10 to 0.06; P = .70), and changes from baseline to 72 hours in normal feeding (difference in differences, 0.03; 95% CI, -0.10 to 0.17; P = .62), normal sleeping (difference in differences, 0.05; 95% CI, -0.08 to 0.18; P = .47), or normal parental sleeping (difference in differences, 0.10; 95% CI, -0.02 to 0.23; P = .09). Parents in the minimal suction group were less satisfied with the assigned device (62 of 184 [33.7%]) than parents in the enhanced suction group (145 of 183 [79.2%]) (risk difference, 0.45; 95% CI, 0.36 to 0.54; P < .001). Conclusions and Relevance: Compared with minimal suctioning, enhanced suctioning after ED discharge with bronchiolitis did not alter the disease course because there were no group differences in revisits or feeding and sleeping adequacy. Minimal suctioning resulted in higher use of nonassigned suctioning devices and lower parental satisfaction with the assigned device. Trial Registration: ClinicalTrials.gov Identifier: NCT03361371.

Incidence and prevalence of neurofibromatosis type 1 and 2: a systematic review and meta-analysis.

OBJECTIVE: To obtain updated estimates of the incidence and prevalence of neurofibromatosis type 1 (NF1) and type 2 (NF2). STUDY DESIGN: We conducted a systematic search of NF1 and NF2 incidence or prevalence studies, in OVID Medline, OVID Embase, Web of Science, and Cinahl. Studies were appraised with the Joanna Briggs Institute Prevalence Critical Appraisal tool. Pooled incidence and prevalence rates were estimated through random-effects meta-analysis. RESULTS: From 1,939 abstracts, 20 studies were fully appraised and 12 were included in the final review. Pooled NF1 prevalence was 1 in 3,164 (95%CI: 1 in 2,132-1 in 4,712). This was higher in studies that screened for NF1, compared to identification of NF1 through medical records (1 in 2,020 and 1 in 4,329, respectively). NF1 pooled birth incidence was 1 in 2,662 (95%CI: 1 in 1,968-1 in 3,601). There were only 2 studies on NF2 prevalence, so data were not pooled. Pooled NF2 birth incidence was 1.08 per 50,000 births (95%CI: 1 in 32,829-1 in 65,019). CONCLUSION: We present updated estimates of the incidence and prevalence of NF1 and NF2, to help plan for healthcare access and allocation. The prevalence of NF1 from screening studies is higher than from medical record studies, suggesting that the disease may be under recognized. More studies are needed regarding the prevalence of NF2.

A Feeding Adequacy Scale for Children With Bronchiolitis: Prospective Multicenter Study.

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

Examining the Double Burden of Underweight, Overweight/Obesity and Iron Deficiency among Young Children in a Canadian Primary Care Setting.

There is little evidence on the prevalence of the double burden and association between body mass index (BMI) and iron deficiency among young children living in high-income countries. We conducted a cross-sectional study of healthy children, 12-29 months of age, recruited during health supervision visits in Toronto, Canada, and concurrently measured BMI and serum ferritin. The prevalence of a double burden of underweight (zBMI < -2) and iron deficiency or overweight/obesity (zBMI > 2) and iron deficiency was calculated. Regression models examined BMI and serum ferritin as continuous and categorical variables, adjusted for covariates. We found the following in terms of prevalence among 1953 children (mean age 18.3 months): underweight 2.6%, overweight/obesity 4.9%, iron deficiency 13.8%, iron-deficiency anemia 5.4%, underweight and iron deficiency 0.4%, overweight/obesity and iron deficiency 1.0%. The change in median serum ferritin for each unit of zBMI was -1.31 µg/L (95% CI -1.93, -0.68, p < 0.001). Compared with normal weight, we found no association between underweight and iron deficiency; meanwhile, overweight/obesity was associated with a higher odds of iron deficiency (OR 2.15, 95% CI 1.22, 3.78, p = 0.008). A double burden of overweight/obesity and iron deficiency occurs in about 1.0% of young children in this high-income setting. For risk stratification and targeted screening in young children, overweight/obesity should be added to the list of important risk factors.

Abscess volume as a predictor of surgical intervention in children hospitalized with orbital cellulitis: A multicentre cohort study.

IMPORTANCE: Orbital cellulitis with subperiosteal or orbital abscess can result in serious morbidity and mortality in children. Objective volume criterion measurement on cross-sectional imaging is a useful clinical tool to identify patients with abscess who may require surgical drainage. OBJECTIVE: To determine the predictive value of abscess volume and the optimal volume cut-point for surgical intervention. DESIGN: We conducted an observational cohort study using medical records from children hospitalized between 2009 and 2018. SETTING: Multicentre study using data from 6 children's hospitals. PARTICIPANTS: Children were included if they were between 2 months and 18 years of age and hospitalized for an orbital infection with an abscess confirmed on cross-sectional imaging. EXPOSURE: Subperiosteal or orbital abscess volume. MAIN OUTCOME AND MEASURES: The primary outcome was surgical intervention, defined as subperiosteal and/or orbital abscess drainage. Multivariable logistic regression was performed to assess the association of abscess volume with surgery. To determine the optimal abscess volume cut-point, receiver operating characteristic (ROC) analysis was performed using the Youden Index to optimize sensitivity and specificity. RESULTS: Of the 150 participants (mean [SD] age, 8.5 [4.5] years), 68 (45.3%) underwent surgical intervention. On multivariable analysis, larger abscess volume and non-medial abscess location were associated with surgical intervention (abscess volume: adjusted odds ratio [aOR], 1.46; 95% CI, 1.11-1.93; abscess location: aOR, 3.46; 95% CI, 1.4-8.58). ROC analysis demonstrated an optimal abscess volume cut-point of 1.18 mL [AUC: 0.75 (95% CI 0.67-0.83) sensitivity: 66%; specificity: 79%]. CONCLUSIONS AND RELEVANCE: In this multicentre cohort study of 150 children with subperiosteal or orbital abscess, larger abscess volume and non-medial abscess location were significant predictors of surgical intervention. Children with abscesses >1.18 mL should be considered for surgery.

Diagnostic test accuracy of ultrasound for orbital cellulitis: A systematic review.

BACKGROUND: Periorbital and orbital cellulitis are inflammatory conditions of the eye that can be difficult to distinguish using clinical examination alone. Computer tomography (CT) scans are often used to differentiate these two infections and to evaluate for complications. Orbital ultrasound (US) could be used as a diagnostic tool to supplement or replace CT scans as the main diagnostic modality. No prior systematic review has evaluated the diagnostic test accuracy (DTA) of ultrasound compared to cross-sectional imaging. OBJECTIVE: To conduct a systematic review of studies evaluating the DTA of orbital ultrasound compared with cross-sectional imaging, to diagnose orbital cellulitis. METHODS: MEDLINE, EMBASE, CENTRAL, and Web of Science were searched from inception to August 10, 2022. All study types were included that enrolled patients of any age with suspected or diagnosed orbital cellulitis who underwent ultrasound and a diagnostic reference standard (i.e., CT or magnetic resonance imaging [MRI]). Two authors screened titles/abstracts for inclusion, extracted data, and assessed the risk of bias. RESULTS: Of the 3548 studies identified, 20 were included: 3 cohort studies and 17 case reports/series. None of the cohort studies directly compared the diagnostic accuracy of ultrasound with CT or MRI, and all had high risk of bias. Among the 46 participants, diagnostic findings were interpretable in 18 (39%) cases which reported 100% accuracy. We were unable to calculate sensitivity and specificity due to limited data. In the descriptive analysis of the case reports, ultrasound was able to diagnose orbital cellulitis in most (n = 21/23) cases. CONCLUSION: Few studies have evaluated the diagnostic accuracy of orbital ultrasound for orbital cellulitis. The limited evidence based on low quality studies suggests that ultrasound may provide helpful diagnostic information to differentiate orbital inflammation. Future research should focus studies to determine the accuracy of orbital US and potentially reduce unnecessary exposure to radiation.