PRISMA flowchart.

<p>PRISMA flowchart.</p

Vitamin D Supplementation for Childhood Asthma: A Systematic Review and Meta-Analysis

<div><p>Importance</p><p>There is growing evidence that vitamin D plays a role in the pathogenesis of asthma but it is unclear whether supplementation during childhood may improve asthma outcomes.</p><p>Objectives</p><p>The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of vitamin D supplementation as a treatment or adjunct treatment for asthma.</p><p>Data Sources</p><p>We searched MEDLINE, Embase, CENTRAL, and CINAHL through July 2014.</p><p>Study Selection</p><p>We included RCTs that evaluated vitamin D supplementation in children versus active control or placebo for asthma.</p><p>Data Extraction and Synthesis</p><p>One reviewer extracted data and one reviewer verified data accuracy. We qualitatively summarized the main results of efficacy and safety and meta-analyzed data on comparable outcomes across studies. We used GRADE for strength of evidence.</p><p>Main Outcome Measures</p><p>Main planned outcomes measures were ED visits and hospitalizations. As secondary outcomes, we examined measures of asthma control, including frequency of asthma exacerbations, asthma symptom scores, measures of lung function, β₂-agonist use and daily steroid use, adverse events and 25-hydroxyvitamin D levels.</p><p>Results</p><p>Eight RCTs (one parallel, one crossover design) comprising 573 children aged 3 to 18 years were included. One study (moderate-quality, n = 100) reported significantly less ED visits for children treated with vitamin D. No other studies examined the primary outcome (ED visits and hospitalizations). There was a reduced risk of asthma exacerbations in children receiving vitamin D (low-quality; RR 0.41, 95% CI 0.27 to 0.63, 3 studies, n = 378). There was no significant effect for asthma symptom scores and lung function. The serum 25(OH)D level was higher in the vitamin D group at the end of the intervention (low-quality; MD 19.66 nmol/L, 95% CI 5.96 nmol/L to 33.37 nmol/L, 5 studies, n = 167).</p><p>Limitations</p><p>We identified a high degree of clinical diversity (interventions and outcomes) and methodological heterogeneity (sample size and risk of bias) in included trials.</p><p>Conclusions and Relevance</p><p>Randomized controlled trials provide some low-quality evidence to support vitamin D supplementation for the reduction of asthma exacerbations. Evidence on the benefits of vitamin D supplementation for other asthma-related outcomes in children is either limited or inconclusive. We recommend that future trials focus on patient-relevant outcomes that are comparable across studies, including standardized definitions of asthma exacerbations.</p></div

Reported asthma-related outcomes of included trials.

<p>Abbreviations: NS, non-significant effect; FEV1, forced expiratory volume in 1 second; PEF, peak expiratory flow;</p><p>^<b>↑</b>, intervention significantly increased outcome measure as compared to control (P<0.05);</p><p>^<b>↓</b> intervention significantly decreased outcome measure as compared to control (P<0.05).</p><p>*Shows effect direction between intervention and control at the end of follow-up.</p><p>^†Asthma symptoms score based on different scoring systems.</p><p>^‡As defined by asthma exacerbation attacks.</p><p>Outcome based on two different units of measurement: number of children experiencing asthma exacerbation and number of asthma exacerbation during treatment period.</p><p>Reported asthma-related outcomes of included trials.</p

Forest plot of asthma exacerbations.

<p>Forest plot of asthma exacerbations.</p

Quality assessment (GRADE evidence profile).

<p>Abbreviations: ACT, Asthma Control Test; ATAQ, Asthma Therapy Assessment Questionnaire; ACQ, Asthma Control Questionnaire; FEV1, forced expiratory volume in 1 second; PEF, peak expiratory flow rate.</p><p>^aUnclear allocation concealment, blinding of participants and outcome assessors, accounting of patients and outcome events, and other risk of bias (carryover effects in crossover trial).</p><p>^bUnclear allocation concealment, blinding of participants and outcome assessors, accounting of patients and outcome events.</p><p>^cDifferences in interventions and outcomes measured across studies.</p><p>^dNon-significant effect across studies not included in the meta-analysis.</p><p>^eWeighted difference in mean (WMD) change between intervention and control group.</p><p>^fRisk ratio (RR): risk of experiencing asthma exacerbation in the intervention group as compared to the control group.</p><p>^gNot included in the meta-analysis; favours intervention group.</p><p>^hSignificant statistical heterogeneity observed based on random effects meta-analysis.</p><p>ⁱWeighted mean difference (WMD) at end of intervention between intervention and control group.</p><p>Quality assessment (GRADE evidence profile).</p

Characteristics of included studies.

<p>Abbreviations: w, winter; sp, spring; su, summer; f, fall; NR, not reported; HDM, house dust mites; SIT, specific immunotherapy; ED, emergency department visits; AE, asthma exacerbations; AS, asthma severity/symptoms; ICS, inhaled corticosteroid use; β₂, β₂ agonist use; LF, lung function; VD, serum 25(OH)D concentration; AdvE, adverse events.</p><p>^a55 participants were randomized into three groups: pharmacotherapy group, SIT group, SIT + vitamin D group. Only SIT (n = 15) and SIT + vitamin D (n = 17) were included in this review (n = 32).</p><p>^b430 participants were randomized into vitamin D or placebo group. Only those who were previously diagnosed with asthma were used in the calculation of the RR presented in the meta-analysis (n = 230).</p><p>^c54 participants were randomized into three groups: placebo group, steroid group, steroid + vitamin D group. Only steroid group (n = 18) and steroid + vitamin D group (n = 18) were used (n = 36).</p><p>^dInformation obtained directly from authors.</p><p>Characteristics of included studies.</p

Impact of the COVID-19 era on preventative primary care for children 0-5 years old: a scoping review protocol

Background: The COVID-19 pandemic has resulted in widespread disruptions to primary healthcare delivery and shifts to virtual care. Reduced in-person paediatric primary care visit rates have been reported. However, the extent to which access to primary preventative care has been impacted remains unclear. The objective of this scoping review is to characterise the utilisation of preventative primary care and its association with child development for children ages 0-5 years old during the COVID-19 era. In addition, we will determine if specific groups of children are at greater risk for reduced access to care. Methods: A systematic search will be conducted for studies published between March 11, 2020, and October 2023 in the following databases: MEDLINE (Ovid), Embase (Ovid), Cochrane Library (CENTRAL and CDSR), Web of Science, and CINAHL (EBSCOhost). This scoping review will follow the methodological framework developed by Arksey and O'Malley and updated by the Joanna Briggs Institute (JBI). Studies related to primary preventative care of children aged 0-5 years old conducted in English and in high-income countries will be screened. Studies published before March 11, 2020, in acute care and low-middle-income settings will be excluded. Results will be summarised for appointments attended, delayed, and missed. In addition, we will summarise findings on the impact of COVID-19 on child development. Findings will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Discussion: Further investigation is required to better understand the relationship between attendance of preventative primary care for children and its effects on child development. The findings obtained from this review will offer essential context to guide policy-making and healthcare service planning for the period following the pandemic.</p

Cow’s Milk Fat Obesity pRevention Trial (CoMFORT): a primary care embedded randomised controlled trial protocol to determine the effect of cow’s milk fat on child adiposity

Introduction Cow’s milk is a dietary staple for children in North America. Though clinical guidelines suggest children transition from whole (3.25% fat) milk to reduced (1% or 2%) fat milk at age 2 years, recent epidemiological evidence supports a link between whole milk consumption and lower adiposity in children. The purpose of this trial is to determine which milk fat recommendation minimises excess adiposity and optimises child nutrition and growth. Methods and analysis Cow’s Milk Fat Obesity pRevention Trial will be a pragmatic, superiority, parallel group randomised controlled trial involving children receiving routine healthcare aged 2 to 4–5 years who are participating in the TARGet Kids! practice-based research network in Toronto, Canada. Children (n=534) will be randomised to receive one of two interventions: (1) a recommendation to consume whole milk or (2) a recommendation to consume reduced (1%) fat milk. The primary outcome is adiposity measured by body mass index z-score and waist circumference z-score; secondary outcomes will be cognitive development (using the Ages and Stages Questionnaire), vitamin D stores, cardiometabolic health (glucose, high-sensitivity C-reactive protein, non-high density lipoprotein (non-HDL), low density lipoprotein (LDL), triglyceride, HDL and total cholesterol, insulin and diastolic and systolic blood pressure), sugary beverage and total energy intake (measured by 24 hours dietary recall) and cost effectiveness. Outcomes will be measured 24 months postrandomisation and compared using analysis of covariance (ANCOVA), adjusting for baseline measures. Ethics and dissemination Ethics approval has been obtained from Unity Health Toronto and The Hospital for Sick Children. Results will be presented locally, nationally and internationally and published in a peer-reviewed journal. The findings may be helpful to nutrition guidelines for children in effort to reduce childhood obesity using a simple, inexpensive and scalable cow’s milk fat intervention.</p

Reliability of routinely collected anthropometric measurements in primary care

Background Measuring body mass index (BMI) has been proposed as a method of screening for preventive primary care and population surveillance of childhood obesity. However, the accuracy of routinely collected measurements has been questioned. The purpose of this study was to assess the reliability of height, length and weight measurements collected during well-child visits in primary care relative to trained research personnel. Methods A cross-sectional study of measurement reliability was conducted in community pediatric and family medicine primary care practices. Each participating child, ages 0 to 18 years, was measured four consecutive times; twice by a primary care team member (e.g. nurses, practice personnel) and twice by a trained research assistant. Inter- and intra-observer reliability was calculated using the technical error of measurement (TEM), relative TEM (%TEM), and a coefficient of reliability (R). Results Six trained research assistants and 16 primary care team members performed measurements in three practices. All %TEM values for intra-observer reliability of length, height, and weight were classified as ‘acceptable’ ( 99% for both intra- and inter-observer reliability. Length measurements in children Conclusion There was agreement between routine measurements and research measurements although there were some differences in length measurement reliability between practice staff and research assistants. These results provide justification for using routinely collected data from selected primary care practices for secondary purposes such as BMI population surveillance and research.</p