Sarah Carsley

Association Between Total Duration of Breastfeeding and Iron Deficiency

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

Modifiable Determinants of Serum 25-Hydroxyvitamin D Status in Early Childhood: Opportunities for Prevention

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

Factors Associated With Dental Care Utilization in Early Childhood

OBJECTIVES: To identify sociodemographic, dietary, and biological factors associated with families who do not receive dental care in early childhood and to identify risk factors associated with having cavities among children who receive early dental care. METHODS: A cross-sectional study of healthy Canadian children seen for primary health care between September 2011 and January 2013 was conducted through the TARGet Kids! practice-based research network in Toronto, Canada. Adjusted logistic regression was used to determine factors associated with children who were not seen by a dentist in early childhood and to determine risk factors associated with having dental cavities among children who received early dental care. RESULTS: Of the 2505 children included in the analysis, <1% were seen by a dentist by 1 year of age. Older children were less likely to have never been to the dentist (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.87–0.90). Low family income (OR, 2.73; 95% CI, 1.47–5.06), prolonged bottle use (OR, 1.43; 95% CI, 1.03–2.00), and higher intakes of sweetened drinks (OR, 1.20; 95% CI, 1.01–1.42) were associated with increased risk for never having been to the dentist. Among those who had been to the dentist, older children (OR, 1.04; 95% CI, 1.03–1.05), children of low income families (OR, 1.90; 95% CI, 1.17–3.10), and those of East Asian maternal ethnicity (OR, 1.91; 95% CI, 1.10–3.29) were more likely to have dental cavities. CONCLUSIONS: Among healthy urban children seen by a primary care provider, those most susceptible to cavities were least likely to receive early dental care. These findings support the need for publicly funded universal early preventive dental care and underscore the importance for primary care physicians to promote dental care in early childhood.

Association between serum cholesterol and eating behaviours during early childhood: a cross-sectional study.

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

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.

Completeness and accuracy of anthropometric measurements in electronic medical records for children attending primary care

Background Electronic medical records (EMRs) from primary care may be a feasible source of height and weight data. However, the use of EMRs in research has been impeded by lack of standardisation of EMRs systems, data access and concerns about the quality of the data. Objectives The study objectives were to determine the data completeness and accuracy of child heights and weights collected in primary care EMRs, and to identify factors associated with these data quality attributes. Methods A cross-sectional study examining height and weight data for children <19 years from EMRs through the Electronic Medical Record Administrative data Linked Database (EMRALD), a network of family practices across the province of Ontario. Body mass index z-scores were calculated using the World Health Organization Growth Standards and Reference. Results A total of 54,964 children were identified from EMRALD. Overall, 93% had at least one complete set of growth measurements to calculate a body mass index (BMI) z-score. 66.2% of all primary care visits had complete BMI z-score data. After stratifying by visit type 89.9% of well-child visits and 33.9% of sick visits had complete BMI z-score data; incomplete BMI z-score was mainly due to missing height measurements. Only 2.7% of BMI z-score data were excluded due to implausible values. Conclusions Data completeness at well-child visits and overall data accuracy were greater than 90%. EMRs may be a valid source of data to provide estimates of obesity in children who attend primary care.

Examining growth monitoring practices for children in primary care

Growth monitoring is the long-standing practice used to identify children who fall outside healthy growth parameters. It has been proposed as a key activity for childhood obesity prevention.1 Accurate growth monitoring requires specific techniques and equipment and plotting measurements on a growth chart. The objective of this study was to determine if primary care providers follow recommended growth monitoring practices, including measurement techniques, standardised equipment and use of appropriate growth charts at all health visits. An electronic survey was distributed between December 2016 and February 2017. The sampling frame was health professionals (physicians, dietitians, nurses) most responsible for growth measurement in primary care practices in the province of Ontario, Canada. The survey assessed the following: measurement equipment, technique, growth chart use and timing (scheduled and/or …

Persistent High Non-High-Density Lipoprotein Cholesterol in Early Childhood: A Latent Class Growth Model Analysis

Objectives To examine patterns of non–high‐density lipoprotein (HDL) cholesterol in early childhood and identify factors associated with persistent high non‐HDL cholesterol in healthy urban children. Study design We identified all children enrolled in a primary care practice‐based research network called TARGet Kids! (The Applied Research Group for Kids) with ≥3 laboratory measurements of non‐HDL cholesterol. Latent class growth model analysis was performed to identify distinct trajectory groups for non‐HDL cholesterol. Trajectory groups were then categorized into “normal” vs “persistent‐high” non‐HDL cholesterol based on guideline cut‐off values and logistic regression was completed to examine the association between trajectory group and the presence of anthropometric and cardiometabolic risk factors. Results A total of 608 children met inclusion criteria for the trajectory analysis (median age at enrolment = 18.3, IQR = 27.9 months). Four trajectory groups were identified with 2 groups (n = 451) categorized as normal non‐HDL cholesterol and 2 groups (n = 157) as persistent high non‐HDL cholesterol. Family history of high cholesterol (OR 2.04, 95% CI 1.27–3.28) was associated significantly with persistent high non‐HDL cholesterol, whereas East/Southeast Asian vs European ethnicity (OR 0.33, 95% CI 0.14–0.78), longer breastfeeding duration (OR 0.96, 95% CI 0.93–1.00), and greater birth weight (OR 0.69, 95% CI 0.48–1.00) were associated with lower odds of persistent high non‐HDL cholesterol. Conclusions Patterns of non‐HDL cholesterol are identified during early childhood, and family history of high cholesterol was associated most strongly with persistent high non‐HDL cholesterol. Future research should inform the development of a clinical prediction tool for lipids in early childhood to identify children who may benefit from interventions to promote cardiovascular health.

Implementing growth monitoring recommendations.

The Canadian Task Force on Preventive Health Care recommends growth monitoring for all children at all primary care visits to screen for overweight and obesity.[1][1] Height and weight data are not only necessary for primary care providers to monitor the growth of their patients, but also may