Department of Paediatrics

Permanent URI for this collectionhttps://hdl.handle.net/1807/16978

The Department of Paediatrics is committed to medical and allied health care professional education and mentoring through its undergraduate, postgraduate (residency) and continuing education programs. Our faculty participates in the ongoing assessment, adaptation, and improvement of our Undergraduate Medical School Curriculum, Paediatric Residency and CME programs. These processes and programs provide outstanding opportunity for professional development at all levels.

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[Working Title] MiTy Kids: A Multicentre, International Follow-up Study of Offspring of Mothers with Type 2 Diabetes Exposed to Metformin During Pregnancy in the MiTy (Metformin in Women with Type 2 Diabetes in Pregnancy) Randomized Controlled Trial
(Elsevier, 2023-03) Feig, Denice S; Sanchez, Johanna; Murphy, Kellie E; Elizabeth, Asztalos; Zinman, Bernard; Simmons, David; Hagg, Andrea M; Fantus, I George; Lipscombe, Lorraine; Armson, Anthony; Barrett, Jon; Donovan, Lois; Karanicolas, Paul; Tobin, Siobhan; Mangoff, Kathryn; Klein, Gail; Jiang, Yidi; Thomlinson, George; Hamilton, Jill; MiTy Kids Collaborative Group
Background Metformin is increasingly being used during pregnancy, with potentially adverse long-term effects on children. We aimed to examine adiposity in children of women with type 2 diabetes from the Metformin in Women with Type 2 Diabetes in Pregnancy (MiTy) trial, with and without in-utero exposure to metformin, up to 24 months of age. Methods MiTy Kids is a follow-up study that included infants of women who participated in the MiTy randomised controlled trial, receiving either oral 1000 mg metformin twice daily or placebo. Caregivers and researchers remained masked to the type of medication (metformin or placebo) mothers received during their pregnancy. Anthropometric measurements, including weight, height, and skinfold thicknesses, were taken at 3, 6, 12, 18, and 24 months. At 24 months, linear regression was used to compare the BMI Z score and sum of skinfolds in the metformin versus placebo groups, adjusted for confounders. Fractional polynomials were used to assess growth trajectories. This study is registered with ClinicalTrials.gov, NCT01832181. Findings Of the 465 eligible children, 283 (61%) were included from 19 centres in Canada and Australia. At 24 months, there was no difference between groups in mean BMI Z score (0·84 [SD 1·52] with metformin vs 0·91 [1·38] with placebo; mean difference 0·07 [95% CI –0·31 to 0·45], p=0·72) or mean sum of skinfolds (23·0 mm [5·2] vs 23·8 mm [5·4]; mean difference 0·8 mm [–0·7 to 2·3], p=0·31). Metformin was not a predictor of BMI Z score at 24 months of age (mean difference –0·01 [95% CI –0·42 to 0·37], p=0·92). There was no overall difference in BMI trajectory but, in males, trajectories were significantly different by treatment (p=0·048); BMI in the metformin group was higher between 6 and 24 months. Children of women with type 2 diabetes were approximately 1 SD heavier than the WHO reference population. Interpretation Anthropometrics were similar in children exposed and those not exposed to metformin in utero; hence, overall, data are reassuring with regard to the use of metformin during pregnancy in women with type 2 diabetes and the long-term health of their children.
The mediation effect of breastfeeding duration on the relationship between maternal preconception BMI and childhood nutritional risk
(Springer Nature, 2024-03) Braddon, Kate E; Keown-Stoneman, Charles D G; Dennis, Cindy-Lee; Li, Xuedi; Maguire, Jonathon L; O'Connor, Deborah L; Omand, Jessica A; Randall Simpson, Janis; Birken, Catherine S
Background Higher maternal preconception body mass index (BMI) is associated with lower breastfeeding duration, which may contribute to the development of poor child eating behaviours and dietary intake patterns (components of nutritional risk). A higher maternal preconception BMI has been found to be associated with higher child nutritional risk. This study aimed to determine whether breastfeeding duration mediated the association between maternal preconception BMI and child nutritional risk. Methods In this longitudinal cohort study, children ages 18 months to 5 years were recruited from The Applied Research Group for Kids (TARGet Kids!) in Canada. The primary outcome was child nutritional risk, using The NutriSTEP®, a validated, parent-reported questionnaire. Statistical mediation analysis was performed to assess whether total duration of any breastfeeding mediated the association between maternal preconception BMI and child nutritional risk. Results This study included 4733 children with 8611 NutriSTEP® observations. The mean (SD) maternal preconception BMI was 23.6 (4.4) and the mean (SD) breastfeeding duration was 12.4 (8.0) months. Each 1-unit higher maternal preconception BMI was associated with a 0.081 unit higher nutritional risk (95% CI (0.051, 0.112); p < 0.001) (total effect), where 0.011(95% CI (0.006, 0.016); p < 0.001) of that total effect or 13.18% (95% CI: 7.13, 21.25) was mediated through breastfeeding duration. Conclusion Total breastfeeding duration showed to mediate part of the association between maternal preconception BMI and child nutritional risk. Interventions to support breastfeeding in those with higher maternal preconception BMI should be evaluated for their potential effect in reducing nutritional risk in young children.
Hemoglobin Threshold for Blood Transfusion in Young Children Hospitalized with Iron Deficiency Anemia
(Elsevier, 2024-03) Rose Sun, Dou Lin; Puran, Allan; Al Nuaimi, Mohammed; AlRiyami, Layla; Kinlin, Laura M; Kirby-Allen, Melanie; Mahant, Sanjay; Gill, Peter J; Borkhoff, Cornelia M; Parkin, Patricia C
Current recommendations advise against blood transfusion in hemodynamically stable children with iron deficiency anemia (IDA). In an observational study of 125 children ages 6 through 36 months, hospitalized with IDA, 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.
Screening Accuracy of the Parent-Report Preschool Strengths and Difficulties Questionnaire in Primary Care
(Elsevier, 2023-10) Hattangadi, Nayantara; Kay, Tatjana; Parkin, Patricia C; Birken, Catherine S; Maguire, Jonathon L; Szatmari, Peter; van den Heuvel, Meta; Borkhoff, Cornelia M; Charach, Alice
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 24-48 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 semi-structured 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 DSM-5 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 (ICC). Results 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, 22 (21%) had internalizing disorders, and 9 (8%) had externalizing disorders. TDS identified any diagnosis with AUC = 0.67 (95% 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. Conclusion The externalizing subscale has sufficient accuracy and reliability to identify children aged two to four years at risk for attention deficit/hyperactivity disorder and disruptive behavior disorders in primary care.
Association Between Family Income and Positive Developmental Screening Using the Infant Toddler Checklist at the 18-Month Health Supervision Visit
(Elsevier, 2024-01) Nurse, Kimberly M; Parkin, Patricia C; Keown-Stoneman, Charles D G; Bayoumi, Imaan; Birken, Catherine S; Maguire, Jonathon L; Macarthur, Colin; Borkhoff, Cornelia M
Objective: Little is known about whether developmental screening tools identify young children at risk for the “double jeopardy” of developmental delay and social disadvantage. Our objective was to examine the associations between several 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: The number of participants was 2188 (45.5% female, mean age 18.2 months), of which, 285 (13%) had a positive ITC and 1903 (87%) had a negative ITC. The adjusted odds ratio (aOR) for a positive ITC for male compared to female sex was 2.15 (95% CI 1.63, 2.83, p<0.001). The aOR for birthweight was 0.65 per 1 kg increase (95% CI 0.53, 0.80, p<0.001). The aOR for family income of <$40,000 compared to >$150,000 was 3.50 (95% CI 2.22, 5.53, p<0.001); and the aOR for family income between $40,000 to $79,999 compared to >$150,000 was 1.88 (95% CI 1.26, 2.80, p=0.002). Conclusion: 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.
Examining the Double Burden of Underweight, Overweight/Obesity and Iron Deficiency among Young Children in a Canadian Primary Care Setting
(2023-08-18) Borkhoff, Sean A; Parkin, Patricia C; Birken, Catherine S; Maguire, Jonathon L; Macarthur, Colin; Borkhoff, Cornelia M
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.
Maternal Preconception Body Mass Index and Early Childhood Nutritional Risk
(Elsevier, 2023-08) Braddon, Kate E; Keown-Stoneman, Charles Dg; Dennis, Cindy-Lee; Li, Xuedi; Maguire, Jonathon L; O'Connor, Deborah L; Omand, Jessica A; Simpson, Janis Randall; Birken, Catherine S
Background Risk factors for problematic child eating behaviors and food preferences are thought to begin during the preconception period. It is unknown if maternal preconception body mass index (BMI) is associated with child nutritional risk factors (eg, poor dietary intake and eating behaviors). Objectives We aimed to determine whether maternal preconception BMI was associated with child nutritional risk. Methods In this longitudinal cohort study, a secondary data analysis of children ages 18 mo to 5 y were recruited from The Applied Research Group for Kids (TARGet Kids!), a primary care practice-based research network in Canada. The primary exposure was maternal preconception BMI. The primary outcome was parent-reported child nutritional risk score, measured using the Nutrition Screening for Every Preschooler/Toddler (NutriSTEP), an age-appropriate validated questionnaire. Fitted linear mixed effects models analyzed associations between maternal preconception BMI and child nutritional risk after adjusting for covariates. Results This study included 4733 children with 8611 repeated NutriSTEP observations obtained between ages 18 mo to 5 y. The mean (standard deviation [SD]) maternal preconception BMI was 23.6 (4.4), where 73.1% of mothers had a BMI ≤24.9 kg/m2, and 26.9% had a BMI ≥25 kg/m2. The mean (SD) NutriSTEP total score was 13.5 (6.2), with 86.6% at low risk (score <21) and 13.4% at high risk (score ≥21). Each 1 unit increase in maternal preconception BMI was associated with a 0.09 increase in NutriSTEP total score (95% confidence interval [CI]: 0.05, 0.12; P ≤ 0.001). After stratification, each 1 unit increase in maternal BMI was associated with a 0.06 increase in mean NutriSTEP total score (95% CI: 0.007, 0.11; P = 0.025) in toddlers and 0.11 increase in mean NutriSTEP total score (95% CI: 0.07, 0.15; P < 0.001) in preschoolers. Conclusion Higher maternal preconception BMI is associated with slightly higher NutriSTEP total scores. This provides evidence that the preconception period may be an important time to focus on for improving childhood nutrition.
Predictors of Long-Term Neurodevelopmental Outcome of Hypoxic-Ischemic Encephalopathy Treated with Therapeutic Hypothermia
(Thieme, 2020-06) Goswami, Ipsita; Guillot, Mireille; Tam, Emily W Y
Hypoxic-ischemic encephalopathy (HIE) is a manifestation of perinatal asphyxial insult that continues to evolve over days to weeks following the initial injury. Therapeutic hypothermia has demonstrated that a proportion of this secondary brain injury may indeed be preventable. However, therapeutic hypothermia has also altered the prognostic utility of many bedside tools that are commonly used as predictors of long-term neurodevelopmental outcome in HIE. Clinicians are often confronted with uncertainty when assessing the prognosis of infants with HIE. Improved understanding of the implications and limitations of individual investigations may inform clinical decisions and allow for timely intervention. This review summarizes the predictive value of currently available prognostic markers in HIE infants in the therapeutic hypothermia era, including clinical, biochemical, neurophysiological, physiological, and neuroimaging predictors.
Hyperglycemia and Glucose Variability Are Associated with Worse Brain Function and Seizures in Neonatal Encephalopathy: A Prospective Cohort Study
(Elsevier, 2019-06) Pinchefsky, Elana F; Hahn, Cecil D; Kamino, Daphne; Chau, Vann; Brant, Rollin; Moore, Aideen M; Tam, Emily W Y
Objectives To investigate how glucose abnormalities correlate with brain function on amplitude-integrated electroencephalography (aEEG) in infants with neonatal encephalopathy. Study design Neonates born at full term with encephalopathy were enrolled within 6 hours of birth in a prospective cohort study at a pediatric academic referral hospital. Continuous interstitial glucose monitors and aEEG were placed soon after birth and continued for 3 days. Episodes of hypoglycemia (≤50 mg/dL; ≤2.8 mmol/L) and hyperglycemia (>144 mg/dL; >8.0 mmol/L) were identified. aEEG was classified in 6-hour epochs for 3 domains (background, sleep–wake cycling, electrographic seizures). Generalized estimating equations assessed the relationship of hypo- or hyperglycemia with aEEG findings, adjusting for clinical markers of hypoxia-ischemia (Apgar scores, umbilical artery pH, and base deficit). Results Forty-five infants (gestational age 39.5 ± 1.4 weeks) were included (24 males). During aEEG monitoring, 16 episodes of hypoglycemia were detected (9 infants, median duration 77.5, maximum 220 minutes) and 18 episodes of hyperglycemia (13 infants, median duration 237.5, maximum 3125 minutes). Epochs of hypoglycemia were not associated with aEEG changes. Compared with epochs of normoglycemia, epochs of hyperglycemia were associated with worse aEEG background scores (B 1.120, 95% CI 0.501-1.738, P < .001), less sleep–wake cycling (B 0.587, 95% CI 0.417-0.757, P < .001) and more electrographic seizures (B 0.433, 95% CI 0.185-0.681, P = .001), after adjusting for hypoxia–ischemia severity. Conclusions In neonates with encephalopathy, epochs of hyperglycemia were temporally associated with worse global brain function and seizures, even after we adjusted for hypoxia–ischemia severity. Whether hyperglycemia causes neuronal injury or is simply a marker of severe brain injury requires further study.
Predictive Validity of the Infant Toddler Checklist in Primary Care at the 18-month Visit and School Readiness at 4 to 6 Years
(2022-09-17) Nurse, Kimberly M; Janus, Magdalena; Birken, Catherine S; Keown-Stoneman, Charles D G; Omand, Jessica A; Maguire, Jonathon L; Reid-Westoby, Caroline; Duku, Eric; Mamdani, Muhammad; Tremblay, Mark S; Parkin, Patricia C; Borkhoff, Cornelia M
The American Academy of Pediatrics recommends developmental surveillance and screening in early childhood in primary care. The 18-month visit may be an ideal time for identification of children with delays in language and communication, or symptoms of autism spectrum disorder (ASD). Little is known about the predictive validity of developmental screening tools administered at 18 months. Our objective was to examine the predictive validity of the Infant Toddler Checklist (ITC) at the 18-month health supervision visit, using school readiness at kindergarten age as the criterion measure.
Reference intervals for hemoglobin and mean corpuscular volume in an ethnically diverse community sample of Canadian children 2 to 36 months
(2021-05-19) Hamid, Jemila S.; Atenafu, Eshetu G.; Borkhoff, Cornelia M.; Birken, Catherine S.; Maguire, Jonathon L.; Bohn, Mary K.; Adeli, Khosrow; Abdelhaleem, Mohamed; Parkin, Patricia C.
Objective: To establish reference intervals for hemoglobin and mean corpuscular volume (MCV) in an ethnically diverse community sample of Canadian children 36 months and younger. Methods: We collected blood samples from young children at scheduled primary care health supervision visits at 2 weeks, 2, 4, 6, 9, 12, 15, 18, 24, and 36 months of age. Samples were analyzed on the Sysmex XN-9000 Hematology Analyzer. We followed the Clinical and Laboratory Standards Institute guidelines in our analysis. Data were partitioned by sex and also combined. We considered large age partitions (3 and 6 months) as well as monthly partitions. Reference intervals (lower and upper limits) and 90% confidence intervals were calculated. Results: Data from 2106 children were included. The age range was 2 weeks to 36 months, 46% were female, 48% were European and 23% were of mixed ethnicity. For hemoglobin, from 2 to 36 months of age, we found a wide reference interval and the 90% confidence intervals indicated little difference across age groups or according to sex. For MCV, from 2 to 7 months of age there was considerable decrease in the reference interval, which was lowest during the second year of life, followed by a slight increase in the last months of the third year of life. Conclusion: These findings suggest adoption of a single hemoglobin reference interval for children 2–36 months of age. Further studies in children under 4 months of age are needed.
Screening for marginal food security in young children in primary care
(2021-04-23) Bayoumi, Imaan; Birken, Catherine S; Nurse, Kimberly M; Parkin, Patricia C; Maguire, Jonathon L; Macarthur, Colin; Randall Simpson, Janis A; Borkhoff, Cornelia M
Abstract Background Household food insecurity (FI), even at marginal levels, is associated with poor child health outcomes. The Nutrition Screening Tool for Every Preschooler (NutriSTEP®) is a valid and reliable 17-item parent-completed measure of nutrition risk and includes a single item addressing FI which may be a useful child-specific screening tool. We evaluated the diagnostic test properties of the single NutriSTEP® FI question using the 2-item Hunger Vital Sign™ as the criterion measure in a primary care population of healthy children ages 18 months to 5 years. Results The sample included 1174 families, 53 (4.5%) of which were marginally food secure. An affirmative response to the single NutriSTEP® question “I have difficulty buying food I want to feed my child because food is expensive” had a sensitivity of 85% and specificity of 91% and demonstrated good construct validity when compared with the Hunger Vital Sign™. Conclusion The single NutriSTEP® question may be an effective screening tool in clinical practice to identify marginal food security in families with young children and to link families with community-based services or financial assistance programs including tax benefits. Trial registration TARGet Kids! practice-based research network (Registered June 5, 2013 at www.clinicaltrials.gov ; NCT01869530); www.targetkids.ca
Randomized Trial of Oral Iron and Diet Advice versus Diet Advice Alone in Young Children with Non-anemic Iron Deficiency
(Elsevier, 2021-02-04) Parkin, Patricia C; Borkhoff, Cornelia M; Macarthur, Colin; Abdullah, Kawsari; Birken, Catherine S; Fehlings, Darcy; Koroshegyi, Christine; Maguire, Jonathon L; Mamak, Eva; Mamdani, Muhammad; Thorpe, Kevin E; Zlotkin, Stanley H; Zuo, Fei
Objective: To compare the effects of 2 treatment options on neurodevelopmental and laboratory outcomes in young children with nonanemic iron deficiency. Study design: A blinded, placebo-controlled, randomized trial of children 1-3 years with nonanemic iron deficiency (hemoglobin ≥110 g/L, serum ferritin <14 μg/L) was conducted in 8 primary care practices in Toronto, Canada. Interventions included ferrous sulfate or placebo for 4 months; all parents received diet advice. The primary outcome was the Early Learning Composite (ELC) using the Mullen Scales of Early Learning (mean 100, SD 15). Secondary outcomes included serum ferritin. Measurements were obtained at baseline and 4 and 12 months. Sample size was calculated to detect a between-group difference of 6-7 points in ELC. Results: At enrollment (n = 60), mean age was 24.2 (SD 7.4) months and mean serum ferritin was 10.0 (SD 2.4) μg/L. For ELC, the mean between-group difference at 4 months was 1.1 (95% CI −4.2 to 6.5) and at 12 months was 4.1 (95% CI −1.9 to 10.1). For serum ferritin, at 4 months, the mean between-group difference was 16.9 μg/L (95% CI 6.5 to 27.2), and no child randomized to ferrous sulfate had a serum ferritin <14 μg/L (0% vs 31%, P = .003). Conclusions: For young children with nonanemic iron deficiency, treatment options include oral iron and/or diet advice. We remain uncertain about which option is superior with respect to cognitive outcomes; however, adding ferrous sulfate to diet advice resulted in superior serum ferritin outcomes after 4 months. Shared decision-making between practitioners and parents may be considered when selecting either option.
Maternal ethnicity and iron status in early childhood in Toronto, Canada: a cross-sectional study
(BMJ Journals, 2020-04-06) Gunaseelan, Vinusha; Parkin, Patricia C; Wahi, Gita; Birken, Catherine S; Maguire, Jonathon L; Macarthur, Colin; Borkhoff, Cornelia M
Objectives: This study aimed to evaluate the association between maternal ethnicity and iron deficiency (ID) in early childhood, and to evaluate whether infant feeding practices linked to ID differ between maternal ethnic groups. Methods: This was a cross-sectional study of healthy children 1–3 years of age. Adjusted multivariable logistic regression analyses were used to evaluate the association between maternal ethnicity and ID (serum ferritin <12 µg/L) and the association between maternal ethnicity and five infant feeding practices (breastfeeding duration; bottle use beyond 15 months; current formula use; daily cow’s milk intake >2 cups; meat consumption). Results: Of 1851 children included, 12.2% had ID. Compared with the European referent group, we found higher odds of ID among children of South Asian and West Asian/North African maternal ethnicities, and lower odds of ID among children of East Asian maternal ethnicity. Statistically significant covariates associated with higher odds of ID included longer breastfeeding duration and daily cow’s milk intake >2 cups. Current infant formula use was associated with lower odds of ID. Children of South Asian maternal ethnicity had higher odds of bottle use beyond 15 months of age and lower odds of meat consumption. Conclusions: We found increased odds of ID among children of South Asian and West Asian/Northern African maternal ethnicities. We found a higher odds of feeding practices linked to ID in children of South Asian maternal ethnicity, but not in children of West Asian/North African maternal ethnicity. Culturally tailored approaches to providing guidance to parents on healthy infant feeding practices may be important to prevent ID in early childhood.
Association of Family Income and Risk of Food Insecurity With Iron Status in Young Children
(JAMA Network, 2020-07-30) Bayoumi, Imaan; Parkin, Patricia C; Birken, Catherine S; Maguire, Jonathon L; Borkhoff, Cornelia M
Importance: Iron deficiency (ID) has the greatest prevalence in early childhood and has been associated with poor developmental outcomes. Previous research examining associations of income and food insecurity (FI) with ID is inconsistent. Objective: To examine the association of family income and family risk of FI with iron status in healthy young children attending primary care. Design, Setting, and Participants: This cross-sectional study included 1245 children aged 12 to 29 months who attended scheduled primary care supervision visits from 2008 to 2018 in Toronto, Canada, and the surrounding area. Exposures: Family income and risk of FI were collected from parent-reported questionnaires. Children whose parents provided an affirmative response to the 1-item FI screen on the Nutrition Screening Tool for Every Toddler or at least 1 item on the 2-item Hunger Vital Sign FI screening tool were categorized as having family risk of FI. Main Outcomes and Measures: Iron deficiency (serum ferritin level <12 ng/mL) and ID anemia (IDA; serum ferritin level <12 ng/mL and hemoglobin level <11.0 g/dL). All models were adjusted for age, sex, birth weight, body mass index z score, C-reactive protein level, maternal education, breastfeeding duration, bottle use, cow’s milk intake, and formula feeding in the first year. Results: Of 1245 children (595 [47.8%] girls; median [interquartile range] age, 18.1 [13.3-24.0] months), 131 (10.5%) were from households with a family income of less than CAD $40 000 ($29 534), 77 (6.2%) were from families at risk of FI, 185 (14.9%) had ID, and 58 (5.3%) had IDA. The odds of children with a family income of less than CAD $40 000 having ID and IDA were 3 times higher than those of children in the highest family income group (ID: odds ratio [OR], 3.08; 95% CI, 1.66-5.72; P < .001; IDA: OR, 3.28; 95% CI, 1.22-8.87; P = .02). Being in a family at risk of FI, compared with all other children, was not associated with ID or IDA (ID: OR, 0.43; 95% CI, 0.18-1.02; P = .06; IDA: OR, 0.16; 95% CI, 0.02-1.23; P = .08). Conclusions and Relevance: In this study, low family income was associated with increased risk of ID and IDA in young children. Risk of FI was not a risk factor for ID or IDA. These findings suggest that targeting income security may be more effective than targeting access to food to reduce health inequities in the prevention of iron deficiency.
Association between Serum Ferritin and Cognitive Function in Early Childhood
(Elsevier, 2020-02) Parkin, Patricia C; Koroshegyi, Christine; Mamak, Eva; Borkhoff, Cornelia M; Birken, Catherine S; Maguire, Jonathon L; Thorpe, Kevin E
In infants 1-3 years of age, we found higher serum ferritin values associated with higher cognitive function, as measured by the Mullen Scales of Early Learning (P = .02 for the nonlinear relationship). A serum ferritin of 17 μg/L corresponded to the maximum level of cognition, beyond which there was no meaningful improvement.
Total Breastfeeding Duration and Household Food Insecurity in Healthy Urban Children
(Elsevier, 2019) Wong, Peter D; Parkin, Patricia C; Moodie, Rosemary G; Dai, David W H; Maguire, Jonathon L; Birken, Catherine S; Borkhoff, Cornelia M
Objective: Health care policy positions breastfeeding as an important part of the solution to household food insecurity; however, there are critical gaps in our knowledge of the relationship between breastfeeding duration (exposure variable) and household food insecurity (outcome variable). Our objective was to examine this relationship. Methods: A cross-sectional study was conducted from 2008 to 2016 of healthy urban children (N = 3838) who were 0 to 3 years old and recruited from The Applied Research Group for Kids (TARGet Kids!), a practice-based research network in Toronto, Canada. Total breastfeeding duration was collected from parent-reported questionnaires. Household food insecurity was measured using 1-item and 2-item food insecurity screens. Multivariable regression analysis was performed adjusting for prespecified covariates. Results: The median total breastfeeding duration was 10.5 months (interquartile range, 6.0–14.0), and 14.7% of households were food insecure. After adjusting for child characteristics (age, sex), maternal characteristics (age, ethnicity, education, employment), and family characteristics (number of children, single parent family, neighborhood equity score), there was no significant association between total breastfeeding duration and household food insecurity (odds ratio, 0.99; 95% confidence interval, 0.98–1.01). Although low-income families had an increased odds of being household food insecure (P ≤ .001), we found no significant association between total breastfeeding duration and household food insecurity at varying income levels. Conclusions: We found no association between breastfeeding duration and household food insecurity, regardless of family income. Although breastfeeding is associated with improved child health outcomes and considered to be part of the solution to household food insecurity, interventions focused on social determinants may provide more promising targets for the prevention of household food insecurity.
25-hydroxyvitamin D and health service utilization for asthma in early childhood
(Wiley, 2018-08) Omand, Jessica A; To, Teresa; O'Connor, Deborah L; Parkin, Patricia C; Birken, Catherine S; Thorpe, Kevin E; Maguire, Jonathon L
Background: Asthma 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. The primary objective was to determine if vitamin D serum levels in early childhood were associated with HSU for asthma including: a) hospital admissions; b) emergency department visits; and c) outpatient sick visits. Secondary objectives were to determine whether vitamin D supplementation in pregnancy or childhood were associated with HSU for asthma. Methods: Prospective cohort study of children participating in the TARGet Kids!practice-based research network between 2008 and 2013 in Toronto, Canada. HSU was determined by linking each child's provincial health insurance number to health administrative databases. Multi variable quasi-Poisson and logistic regression were used to evaluate the association between 25-hydroxyvitamin D concentrations, vitamin D supplementation in pregnancy, and childhood and HSU for asthma. Results: A total of 2926 healthy children aged 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 concentrations <50 nmol/L and <75 nmol/L, respectively. In the adjusted models,there were no associations between 25-hydroxyvitamin D concentrations (continuously or dichotomized at 50 and 75 nmol/L), vitamin D supplementation in pregnancy or childhood and HSU for asthma. Conclusions: Vitamin D blood values do not appear to be associated with HSU for asthma in this population of healthy urban children.
Minimizing the risk of preoperative brain injury in neonates with aortic arch obstruction
(Elsevier, 2014-10-11) Algra, Selma O; Haas, Felix; Poskitt, Kenneth J; Groenendaal, Floris; Schouten, Antonius N J; Jansen, Nicolaas J G; Azakie, Anthony; Gandhi, Sanjiv; Campbell, Andrew; Miller, Steven P; McQuillen, Patrick S; de Vries, Linda S
Objective—To determine whether prenatal diagnosis lowers the risk of preoperative brain injury by assessing differences in the incidence of preoperative brain injury across centers. Study design—From 2 prospective cohorts of newborns with complex congenital heart disease studied by preoperative cerebral magnetic resonance imaging, one cohort from the University Medical Center Utrecht (UMCU) and a combined cohort from the University of California San Francisco (UCSF) and University of British Columbia (UBC), patients with aortic arch obstruction were selected and their imaging and clinical course reviewed. Results—Birth characteristics were comparable between UMCU (n = 33) and UCSF/UBC (n = 54). Patients had a hypoplastic aortic arch with either coarctation/interruption or hypoplastic left heart syndrome. In subjects with prenatal diagnosis, there was a significant difference in the prevalence of white matter injury (WMI) between centers (11 of 22 [50%] at UMCU vs 4 of 30 [13%] at UCSF/UBC; P < .01). Prenatal diagnosis was protective for WMI at UCSF/UBC (13% prenatal diagnoses vs 50% postnatal diagnoses; P < .01), but not at UMCU (50% vs 46%, respectively; P > .99). Differences in clinical practice between prenatally diagnosed subjects at UMCU vs UCSF/UBC included older age at surgery, less time spent in the intensive care unit, greater use of diuretics, less use of total parenteral nutrition (P < .01), and a greater incidence of infections (P = .01). In patients diagnosed postnatally, the prevalence of WMI was similar in the 2 centers (46%at UMCU vs 50% at UCSF/UBC; P > .99). Stroke prevalence was similar in the 2 centers regardless of prenatal diagnosis (prenatal diagnosis: 4.5% at Utrecht vs 6.7% at UCSF/ UBC, P = .75; postnatal diagnosis: 9.1% vs 13%, respectively, P > .99). Conclusion—Prenatal diagnosis can be protective for WMI, but this protection may be dependent on specific clinical management practices that differ across centers.
Brain in Congenital Heart Disease Across the Lifespan: The Cumulative Burden of Injury
(American Heart Association, 2016-05-17) Marelli, Ariane; Miller, Steven P; Marino, Bradley Scott; Jefferson, Angela L; Newburger, Jane W
The number of patients surviving with congenital heart disease (CHD) has soared over the last 3 decades. Adults constitute the fastest-growing segment of the CHD population, now outnumbering children. Research to date on the heart-brain intersection in this population has been focused largely on neurodevelopmental outcomes in childhood and adolescence. Mutations in genes that are highly expressed in heart and brain may cause cerebral dysgenesis. Together with altered cerebral perfusion in utero, these factors are associated with abnormalities of brain structure and brain immaturity in a significant portion of neonates with critical CHD even before they undergo cardiac surgery. In infancy and childhood, the brain may be affected by risk factors related to heart disease itself or to its interventional treatments. As children with CHD become adults, they increasingly develop heart failure, atrial fibrillation, hypertension, diabetes mellitus, and coronary disease. These acquired cardiovascular comorbidities can be expected to have effects similar to those in the general population on cerebral blood flow, brain volumes, and dementia. In both children and adults, cardiovascular disease may have adverse effects on achievement, executive function, memory, language, social interactions, and quality of life. Against the backdrop of shifting demographics, risk factors for brain injury in the CHD population are cumulative and synergistic. As neurodevelopmental sequelae in children with CHD evolve to cognitive decline or dementia during adulthood, a growing population of CHD can be expected to require support services. We highlight evidence gaps and future research directions.

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