General paediatric research: Abstract summaries and commentaries

As discussed by Dr Gold (pages 385–387), it is encouraging that so many outstanding researchers are devoting their skills and expertise to addressing issues that will ultimately improve the health of Canada's children and youth – a noble cause indeed. The major challenge in selecting significant publications from 2003 that will likely impact on child and youth health stems from both the large number and the high quality of the Canadian research reported last year. Given this daunting but exhilarating challenge, I have selected only a small minority of the reports that our search identified and have attempted to focus on those that have significant public health implications and/or appear to represent new information that will likely be of importance in the day-to-day care provided to our children and youth. Unfortunately, space and time do not permit the inclusion of many additional important papers published by Canadian researchers. I apologize both to the reader and the authors for not including more papers in this review. The alarming and well-recognized epidemic of obesity among Canadian children, youth and adults has already had many adverse health effects and a number of studies have addressed this very important public health issue, including two studies that are reviewed below. Tremblay MS, Willms JD. Is the Canadian childhood obesity epidemic related to physical inactivity? Int J Obes Relat Metab Disord 2003;27:1100–5. Tremblay and Willms, from Saskatoon and Fredericton, studied the physical activity and body mass index (BMI) of 7216 children aged seven to 11 years who participated in the 1994 National Longitudinal Survey of Children and Youth. The data in the National Longitudinal Survey of Children and Youth included parental reports of height and weight, which were used to calculate BMI. Children with calculated cut-off BMIs (BMI>25 kg/m2) were classified as overweight and those with a BMI greater than 30 kg/m2 were classified as obese. Parental responses were used to identify the amount and type of the children's physical activity. Both overweight and obesity were more common among children from families with lower socioeconomic status (SES) and among those from single parent families. When SES and family structure data were controlled, BMI was still significantly higher among the less active children. Both organized and unorganized sport participation was negatively associated with both overweight (10% to 24% reduced risk) and obesity (23% to 43% reduced risk), while television watching and video game playing were positively associated with being overweight (17% to 44% increased risk) and being obese (10% to 61% increased risk). Watching more than 2 h/day of television was significantly associated with an increased risk of both overweight and obesity. Physical activity and sedentary behaviour were partially due to the effects of SES and family structure, but still remained significant when SES and family structure were considered. The authors also documented that participating in art and dance was negatively associated with both overweight and obesity. Trudeau F, Shephard RJ, Bouchard S, Laurencelle L. BMI in the Trois-Rivières study: Child-adult and child-parent relationships. Am J Human Biol 2003;15:187–91. Trudeau et al, from Trois-Rivières and Toronto, studied the relationship between parental BMI and adult BMI in a cohort of 114 French Canadian children measured at 10 to 12 years of age from 1970 to 1977 and, again, at follow-up from 1996 to 1998 (mean age at second measurement was 34.9 years). The children had been enrolled in the Trois-Rivières semilongitudinal study of growth and development and were compared with their parents. BMI increased as expected during the study interval, and, as adults, the children had slightly greater BMIs than did their parents at a comparable age. Regression analysis of adult BMIs related statistically only with childhood BMIs but not with parental BMIs. The study was not designed to determine the relative contributions of muscle mass compared to fat in the adult BMIs, but it was clear that childhood BMI was a much better predictor of adult BMI than parental BMI. Comment: Both the Tremblay and Willms and the Trudeau et al studies address an increasingly important public health concern regarding the predictors and probable causes of adult obesity. The Trudeau et al study suggests that while genetic factors are likely important in the etiology of obesity, parental BMI when the children are 10 to 12 years of age may not be a reliable predictor of adult BMI and, by inference, obesity. However, BMI during childhood was a significant predictor of adult BMI. Whether a similar study done in 2004 would confirm this relationship is unknown, but Tremblay and Willms' data strongly suggest that a modifiable determinant of obesity is the amount of physical activity done by seven- to 11-year-old children. Clearly, increased physical activity and decreased sedentary behaviour, including television watching and video game use, are practical and potentially achievable goals for paediatricians and family physicians to recommend and monitor in their paediatric patients. It is clear that obesity and overweight can, and do, begin in childhood. The increasing burden of obesity among Canadian children and youth supports the need for child health practitioners to advocate physical activity for their own patients as well as in their community leadership roles. Langille DB, Curtis L, Hughes J, Murphy GT. Association of socio-economic factors with health risk behaviours among high school students in rural Nova Scotia. Can J Public Health 2003;94:442–7. Langille et al from Halifax surveyed grade 10 to 12 students in four northern Nova Scotia high schools to determine the association between SES and a number of variables, including substance abuse, sexual behaviour and suicide attempts. The surveys were done by trained teachers during class time in 2000. Seventy-nine per cent of eligible students participated in the study (2198 students, 48% males, 52% males, age range of 14 to 20 years). The data revealed that almost 25% of students smoked, 19% of males and 8% of females had used marijuana more than 10 times in the past month, over 30% had more than five drinks on at least one occasion in the previous month, more than 10% had intercourse before age 15, and 3% of males and 4% to 8% of females had attempted suicide. Drinking and driving was reported by over 14% of grade 12 males. Among both males and females, smoking was the behaviour most associated with a lower SES. Both parental education and employment were found to be related to substance abuse, with those mothers with postsecondary education having fewer children smoking, while the father's education was similarly related to decreased heavy drinking behaviour. Adolescents living with single parents were more likely to smoke, use marijuana and have early intercourse. The only SES variable associated with suicide attempts was lower maternal education. Séguin L, Xu Q, Potvin L, Zunzunegui MV, Frohlich KL. Effects of low income on infant health. CMAJ 2003;168:1533–8. In 1998, Séguin et al from Montreal interviewed 2223 mothers of five-month-old (range 15 to 36 weeks) Quebec infants participating in the Quebec Longitudinal Study of Child Development. Premature infants were not included. As part of this population-based study, the authors reviewed the infants' health records to determine their neonatal health status and asked the mothers about their baby's health. Statistics Canada's low-income thresholds were used to determine income level. A family that devotes 20% more of its before-tax income to food, shelter and clothing than does the average family was considered low-income. The income used to indicate a “moderately inadequate” income for a family of three was between $16,238 and $27,063, and a “very inadequate” income was less than $16,238. The participation rate of eligible families was 83.1%, although the final rate fell to 75.8% when nonresponders for some of the data sets were excluded. The lowest response rates were from mothers with the lowest levels of education and those who spoke neither French nor English. Twelve per cent of infants lived in households with moderately inadequate family incomes and 15.5% lived in households with very inadequate family incomes. Over 31% of mothers with moderately or very inadequate incomes perceived their baby's health to be less than excellent compared with 20% of mothers with sufficient income. Significantly more mothers with low incomes reported chronic health problems than did mothers with sufficient income. Infants of mothers with moderately inadequate income were admitted to hospital since birth significantly more often (21%) than were infants of mothers with sufficient income (11%) or very inadequate income (13%). Using stepwise regression multivariate analysis and adjusting for infant characteristics and neonatal health, mothers with inadequate incomes still perceived that their infants had less than excellent health, and those with moderately inadequate incomes, but not very inadequate incomes, had significantly more admissions to hospital. The factors leading to the significantly increased admissions to hospital in the infants of those families with moderately inadequate incomes but not those from very inadequate incomes were not clear. Comment: The Langille et al and Séguin et al studies demonstrate that social factors and low income impact on child health, during both infancy and adolescence. While these results are neither surprising nor unexpected, they highlight the negative effects that social factors such as low parental education and, especially, family poverty have on child and youth health. The high rate of drinking and driving among Nova Scotia teenagers was also demonstrated in Ontario by Adlaf et al (1). The Langille et al and Adlaf et al studies highlight the adolescent component of drinking and driving, which like obesity, is a major public health problem, and physicians who care for children and youth may play an important role in its prevention. Other Canadian publications last year identified the negative impact of poverty on the availability of medications for children with significant disease (2) and the effect of maternal education, and to a lesser extent, low income, on infant breastfeeding (3). The effect of low family income on hospital admissions reported in the Séguin et al study remains unexplained but is consistent with the report from Alberta by Sin et al (4) of the impact of family income on emergency department use by children with asthma from low income families. When taken together, these papers and others demonstrate the huge effects of social factors on health, particularly child and youth health. Canadian researchers have provided clear evidence of some of the negative impacts on child health of poor parental education and poverty. The challenge for all of us involved in child and youth health is how best to intervene to prevent or at least ameliorate these negative effects. French MR, Barr SI, Levy-Milne R. Folate intakes and awareness of folate to prevent neural tube defects: A survey of women living in Vancouver, Canada. J Am Diet Assoc 2003;103:181–5. French et al from Toronto and Vancouver interviewed a randomly selected cohort of Vancouver women between the ages of 18 and 45 years to determine their folate intake, and their knowledge and awareness of the relationship between folate intake and neural tube defects (NTD). Only women fluent in English were eligible, and those who were pregnant or had been pregnant in the previous six months were excluded. One hundred forty-eight women completed the study, which represented 35.7% of the households contacted by the investigators. Eligible women who refused to complete the survey were significantly more likely to have children and less likely to have heard of folate than those who completed the survey tool. Ninety-nine per cent of the women had completed high school, 69% had annual incomes greater than were and had children. Folate intake was related to the of folate of and In the of of women fell the average folate but with and only fell the with folate 14% of the women still fell the In of women had heard of folate but only that it was important during Only 20 women folate be taken before to the risk of birth who had children were significantly more of the need for folate during than were women who had children. women that they would be to folate during it was demonstrated that it would the risk of A large of women that their family would be a of information about of the women who had discussed folate with their were of the relationship between folate and health, compared with only of those who had not discussed the with their Comment: Given the of folate intake in the of and the French et al study is both encouraging and the of to in an effect that is likely at least in to the use of folate It is encouraging that those women who had discussed the with their family were and that most women would likely a they the evidence of its is for physicians to intervene on a public health that has significant to in and child health in However, the that with and folate a significant number of women do not the amount of folate that would be expected to the risk of is study by French from Ontario suggests that a additional of folate may be a in the second most common during childhood. the rates of nor in childhood to be related to folate While the effect of folate on the rates of childhood remains to be it is well that folate has in and all physicians involved in the care of women who are in their years to the of folate intake, before and childhood Health study attempted to determine the importance of in the development of in Quebec children. of children 14 years of age with between and 1998, and of were asked about the number of their children had A single did not the risk of to two or more increased the risk to The of were similar in both and In the second part of this study, children with were for in which may be important in the genetic done by of four were and their association with was of the not to be associated with a in the was of an increased risk among and a reduced risk among was an that a in the may lower the risk of in Comment: is the most common in children and its etiology is almost a of genetic and study suggests that children who have more than one may have a slightly greater risk of than children who have only one or The was only increased and, although statistically the relative importance of in the development of remains The association of and be as additional evidence that may be a risk for and with may be at higher risk than It would be research identify children at increased risk of or potentially to lower this risk in these children. In this Quebec authors have addressed the role of and the risk of childhood The study by et al that the play a role in the etiology of data are but highlight the being in the to both the and genetic factors that are important and in the development of childhood While are not at the the of the genetic to to the of these studies are consistent with the to the amount of children of among one of an J study from Vancouver the of in the had the rate of in at per compared with the average of per The involved of grade students, and in infant was to the The authors documented annual and disease rates data from the for that from to of grade students for year between and Both the number of of and the rate per significantly from to when the study The rate among the cohort of and adults eligible for fell from to per were of in this age in The had effects in and rural with having only a in to compared with a in rural to Comment: study the rate of in since the of the In the authors the of in and an in the rate in the was the to and all Canadian have The data in this report the development of in The authors that in of and also be important factors in the of in the study also suggests that the was more in rural than in the burden and number of is – that additional are to the impact of on The in in children and is particularly and is of the of childhood at the level. Can J Public Health et al from Quebec addressed the low use of among Quebec children the that a of parents of the of that they were in the for their children. and were used to data about a number of as well as the status of to children in the Quebec which over of the children in the The parents of of of the eligible children were contacted and over of these to in the of parents were of the only reported that their the it was a but only the was a public health or a with parents and higher maternal education were significantly more likely to have been the Among those the were with significantly more children the among those with mothers and from families. In the type of public health or did not among those who to have their children The more information the the the more likely the children the on was per cent of parents who refused the of the of the as the for their while that it was the Among those not the that they would have been in the but 43% when of the of the of those with higher incomes remained in being of the Among those parents who were not in when of the 61% when of the of Comment: In the National on for children than 12 as well as others at risk of but in most the of is not included in and the be by the or The et al study that the of is a to for families. family income impacts negatively on many of child health and, not children from low-income families less likely to the of In it is surprising that only of the children's the to be more when the also more particularly information on the of to be more likely to than were family but in both less than the in many more family or public health are to the children they care and its from some for physicians to advocate public health at our children. the National on are a number of that be before the be et childhood CMAJ et al the factors that among a of children than six The children were from those to the of emergency department between and when the of Ontario of eligible children were a which addressed factors the to have their children Only of the children had been Children who had been did not in parental education or emergency department from those who had not been Children who had family risk to or who had been to were more likely to have had The of parents that and were of of children were significantly more likely to that was a effect of that the effects were than and that would the The most common reported for were of and per cent of parents reported with their but only a small reported that was When was not of children were not regression analysis revealed that two factors were significantly associated with having a child with chronic and with the Comment: study is consistent in many with the report of et al which identified some of the factors that parents to have their children While has been has not such a it was and for all children over six months of age at the time of et study in The National on on that adults and children be to the is an increasing number of reports that suggest is a for in children who are not high but at physicians and families will have to determine the and of children than six months the of While such from both et al and et studies demonstrate the importance of of by physicians with parents and the need to information about the of the In the of is an to like is not by but physicians and the rate of childhood and the burden of these on their patients and families. have the and the at least in to the information on the and of and to to their patients. et Human in the Canadian J from and from three Canadian a study on the of in four public health in an to determine the impact of this on in Canada. reviewed during the to and the characteristics of the patients. was by and were was in of all and identified in all participating of all ages were per cent of those to five 4% of those six to 10 10% of those 11 to 20 25% of those to years and 31% of those than years were with males and females having similar in of and included and muscle in less than 10% of included and per cent of patients were with significantly higher rates of found among patients than five years and than years admitted to hospital also had the rates of and The data demonstrate that was in during the of was a time when were also with many having similar and associated Comment: was in in the and et al have demonstrated that this to be a significant cause of among of all with particularly common and in those than five years and than While more research is to the burden of in it is likely that this is a significant cause of many lower and during the particularly those that are not to and a very common cause of in from the the of and its for the and have reports from the and suggest that has a very similar impact in children, both and to and et al have been at the of the impact of a new that children and adults, and is a significant cause of disease in Canada. research still remains to be done to address issues of and of As need to be to physicians to from common In the will likely be important for research in and type 2 In this et al from and their on the genetic causes of type 2 the of type 2 in Canadian is among the in the has genetic of type 2 and related The most important genetic was the in by the was by and would have been the of was associated with increased of having type 2 the study and in all including adolescent had and of and for type 2 by age The the had in that of the the age of by about seven also that more strongly the of than did which have implications for to the burden of this has also provided evidence for genetic of related including and in the Comment: As type 2 is increasingly in and is at an alarming rate in children and youth. such as and increased intake of are major but as the of has a role in the etiology of type 2 among the and, among as The authors the used to identify the in the which the risk of type 2 in those who have the The to of the which in to but not of including It that in the of the the of obesity and the risk of type 2 as well as its early when the age of of type 2 was compared between before and those it was found that the more cohort had a much age of strongly suggests that the increasing of obesity and a more sedentary are with the which is to have in since in the high rate of type 2 The of and activity with of the for to prevent or the of type 2 it is that be about the importance of and in the may be identified in which more and

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