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IntroductionEvidence suggests the presence of deficiencies in the quality of care provided to up to half of all paediatric trauma patients in Canada, the USA and Australia. Lack of adherence to evidence-based recommendations may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aim to systematically review CPG recommendations for paediatric injury care and appraise their quality.Methods and analysisWe will identify CPG recommendations through a comprehensive search strategy including Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane library, Web of Science, ClinicalTrials and websites of organisations publishing recommendations on paediatric injury care. We will consider CPGs including at least one recommendation targeting paediatric injury populations on any diagnostic or therapeutic intervention from the acute phase of care with any comparator developed in high-income countries in the last 15 years (January 2007 to a maximum of 6 months prior to submission). Pairs of reviewers will independently screen titles, abstracts and full text of eligible articles, extract data and evaluate the quality of CPGs and their recommendations using Appraisal of Guidelines Research and Evaluation (AGREE) II and AGREE Recommendations Excellence instruments, respectively. We will synthesise evidence on recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework and present results within a recommendations matrix.Ethics and disseminationEthics approval is not a requirement as this study is based on available published data. The results of this systematic review will be published in a peer-reviewed journal, presented at international scientific meetings and distributed to healthcare providers.PROSPERO registration numberInternational Prospective Register of Systematic Reviews (CRD42021226934).

The identification of clinical phenotypes may help parse the substantial heterogeneity that characterizes children with concussion. This study used latent class analysis (LCA) to identify discernible phenotypes among children with acute concussion and examine the association between phenotypes and persistent post-concussive symptoms (PPCS) at 4 and 12 weeks post-injury. We conducted LCA of variables representing pre-injury history, clinical presentation, and parent symptom ratings, derived from a prospective cohort, observational study that recruited participants from August 2013 until June 2015 at nine pediatric emergency departments within the Pediatric Emergency Research Canada network. This substudy included 2323 children from the original cohort ages 8.00-17.99 years who had data for at least 80% of all variables included in each LCA. Concussion was defined according to Zurich consensus statement diagnostic criteria. The primary outcome was PPCS at 4 and 12 weeks after enrollment. Participants were 39.5% female and had a mean age of 12.8 years (standard deviation = 2.6). Follow-up was completed by 1980 (85%) at 4 weeks and 1744 (75%) at 12 weeks. LCA identified four groups with discrete pre-injury histories, four groups with discrete clinical presentations, and seven groups with discrete profiles of acute symptoms. Clinical phenotypes based on the profile of group membership across the three LCAs varied significantly in their predicted probability of PPCS at 4 and 12 weeks. The results indicate that children with concussion can be grouped into distinct clinical phenotypes, based on pre-injury history, clinical presentation, and acute symptoms, with markedly different risks of PPCS. With further validation, clinical phenotypes may provide a useful heuristic for clinical assessment and management.

[EN] Importance: Severe outcomes among youths with SARS-CoV-2 infections are poorly characterized. Objective: To estimate the proportion of children with severe outcomes within 14 days of testing positive for SARS-CoV-2 in an emergency department (ED). Design, Setting, and Participants: This prospective cohort study with 14-day follow-up enrolled participants between March 2020 and June 2021. Participants were youths aged younger than 18 years who were tested for SARS-CoV-2 infection at one of 41 EDs across 10 countries including Argentina, Australia, Canada, Costa Rica, Italy, New Zealand, Paraguay, Singapore, Spain, and the United States. Statistical analysis was performed from September to October 2021. Exposures: Acute SARS-CoV-2 infection was determined by nucleic acid (eg, polymerase chain reaction) testing. Main Outcomes and Measures: Severe outcomes, a composite measure defined as intensive interventions during hospitalization (eg, inotropic support, positive pressure ventilation), diagnoses indicating severe organ impairment, or death. Results: Among 3222 enrolled youths who tested positive for SARS-CoV-2 infection, 3221 (>99.9%) had index visit outcome data available, 2007 (62.3%) were from the United States, 1694 (52.6%) were male, and 484 (15.0%) had a self-reported chronic illness; the median (IQR) age was 3 (0-10) years. After 14 days of follow-up, 735 children (22.8% [95% CI, 21.4%-24.3%]) were hospitalized, 107 (3.3% [95% CI, 2.7%-4.0%]) had severe outcomes, and 4 children (0.12% [95% CI, 0.03%-0.32%]) died. Characteristics associated with severe outcomes included being aged 5 to 18 years (age 5 to

IMPORTANCE Approximately one-third of children experiencing acute concussion experience ongoing somatic, cognitive, and psychological or behavioral symptoms, referred to as persistent postconcussion symptoms (PPCS). However, validated and pragmatic tools enabling clinicians to identify patients at risk for PPCS do not exist. OBJECTIVE To derive and validate a clinical risk score for PPCS among children presenting to the emergency department. DESIGN, SETTING, AND PARTICIPANTS Prospective, multicenter cohort study (Predicting and Preventing Postconcussive Problems in Pediatrics [5P]) enrolled young patients (aged 5

* Abbreviations: CONSORT — : Consolidated Standards of Reporting Trials ITT — : intention to treat SPIRIT — : Standard Protocol Items: Recommendations for Interventional Trials StaR Child Health — : Standards for Research in Child Health There is a crisis of credibility facing the child health research community because of the paucity of reliable estimates of the effects of interventions in children. Associations between risk of bias assessments and treatment effect estimates have important implications, for the clinician, and the families face important challenges as decision-makers stemming from results that exaggerate treatment effectiveness or safety. Consequently, interventions that are not efficacious and potentially harmful may be prescribed, whereas interventions that truly are efficacious may be withheld.1–5 Positive trends in pediatric research have been observed since the first trial was published in 1948. Specifically, there has been a substantial increase in the number of trials published over time, the proportion of randomized to nonrandomized controlled trials, and the proportion of child to adult trials.6 Reporting of methods has also improved; however, methodological quality remains modest.6 Three studies have specifically examined risk of bias in pediatric trials by using the Cochrane Risk of Bias tool.7–9 The results are summarized in Table 1 by risk of bias domain. In 2 reviews, the overall risk of bias was unclear or high for the vast majority of trials.7,8 Both of these articles also revealed that trials at high or unclear risk of bias had exaggerated treatment effects compared with those at low risk of bias. Sequence generation and allocation concealment appear to be the domains that are consistently problematic. Importantly, several variables have been found to be associated with risk of bias including source of funding (industry-sponsored research revealing higher risk of bias), nature of the interventions (behavioral/educational interventions having higher risk of bias), and number of authors (higher risk of bias with fewer authors).9 View this table: TABLE 1 Summary of Reviews Documenting Risk of Bias by Domain Using Cochrane Collaboration Risk of … Address correspondence to Martin Offringa, MD, PhD, Senior Scientist and Program Head, Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8. E-mail: martin.offringa{at}sickkids.ca

To review and synthesize the state of research on a variety of meditation practices, including: the specific meditation practices examined; the research designs employed and the conditions and outcomes examined; the efficacy and effectiveness of different meditation practices for the three most studied conditions; the role of effect modifiers on outcomes; and the effects of meditation on physiological and neuropsychological outcomes.Comprehensive searches were conducted in 17 electronic databases of medical and psychological literature up to September 2005. Other sources of potentially relevant studies included hand searches, reference tracking, contact with experts, and gray literature searches.A Delphi method was used to develop a set of parameters to describe meditation practices. Included studies were comparative, on any meditation practice, had more than 10 adult participants, provided quantitative data on health-related outcomes, and published in English. Two independent reviewers assessed study relevance, extracted the data and assessed the methodological quality of the studies.Five broad categories of meditation practices were identified (Mantra meditation, Mindfulness meditation, Yoga, Tai Chi, and Qi Gong). Characterization of the universal or supplemental components of meditation practices was precluded by the theoretical and terminological heterogeneity among practices. Evidence on the state of research in meditation practices was provided in 813 predominantly poor-quality studies. The three most studied conditions were hypertension, other cardiovascular diseases, and substance abuse. Sixty-five intervention studies examined the therapeutic effect of meditation practices for these conditions. Meta-analyses based on low-quality studies and small numbers of hypertensive participants showed that TM(R), Qi Gong and Zen Buddhist meditation significantly reduced blood pressure. Yoga helped reduce stress. Yoga was no better than Mindfulness-based Stress Reduction at reducing anxiety in patients with cardiovascular diseases. No results from substance abuse studies could be combined. The role of effect modifiers in meditation practices has been neglected in the scientific literature. The physiological and neuropsychological effects of meditation practices have been evaluated in 312 poor-quality studies. Meta-analyses of results from 55 studies indicated that some meditation practices produced significant changes in healthy participants.Many uncertainties surround the practice of meditation. Scientific research on meditation practices does not appear to have a common theoretical perspective and is characterized by poor methodological quality. Firm conclusions on the effects of meditation practices in healthcare cannot be drawn based on the available evidence. Future research on meditation practices must be more rigorous in the design and execution of studies and in the analysis and reporting of results.

The objectives of this report are to determine the following: (1) the effectiveness of the toilet training methods, (2) which factors modify the effectiveness of toilet training, (3) if the toilet training methods are risk factor for adverse outcomes, and (4) the optimal toilet training method for achieving bowel and bladder control among patients with special needs.MEDLINE, Ovid MEDLINE In-ProcessOther Non-Indexed Citations, Ovid OLDMEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, PsycINFO, ERIC, EBM Reviews, HealthSTAR, AMED, Web of Science, Biological Abstracts, Sociological Abstracts, OCLC ProceedingsFirst, OCLC PapersFirst, Dissertation Abstracts, Index to Theses, National Research Register's Projects Database, and trials registers.Two reviewers assessed the studies for inclusion. Studies were included if they met the following criteria:RCT, CCT, prospective or retrospective cohort, case-control, cross-sectional or case-series;infants, toddlers, or children with or without co-morbidities, neuromuscular, cognitive, or behavioral handicaps disabilities;at least one toilet training method; andbladder and/or bowel control, successes, failures, adverse outcomes. Methodological quality was assessed independently by two reviewers. Data were extracted by one reviewer and a second checked for accuracy and completeness. Due to substantial heterogeneity, meta-analysis was not possible.Twenty-six observational studies and eight controlled trials were included. Approximately half of the studies examined healthy children while the remaining studies assessed toilet training of mentally or physically handicapped children. For healthy children, the Azrin and Foxx method performed better than the Spock method, while child-oriented combined with negative term avoidance proved better than without. For mentally handicapped children, individual training was superior to group methods; relaxation techniques proved more efficacious than standard methods; operant conditioning was better than conventional treatment, and the Azrin and Foxx and a behavior modification method fared better than no training. The child-oriented approach was not assessed among mentally handicapped children. For children with Hirschsprung's disease or anal atresia, a multi-disciplinary behavior treatment was more efficacious than no treatment.Both the Azrin and Foxx method and the child-oriented approach resulted in quick, successful toilet training, but there was limited information about the sustainability of the training. The two methods were not directly compared, thus it is difficult to draw definitive conclusions regarding the superiority of one method over the other. In general, both programs may be used to teach toilet training to healthy children. The Azrin and Foxx method and operant conditioning methods were consistently effective for toilet training mentally handicapped children. Programs that were adapted to physically handicapped children also resulted in successful toilet training. A lack of data precluded conclusions regarding the development of adverse outcomes.

Airway edema and mucus plugging are the predominant pathological features in infants with acute viral bronchiolitis. Nebulized hypertonic saline solution may reduce these pathological changes and decrease airway obstruction.

To determine the effectiveness of diabetes education on metabolic control, diabetes-related hospitalizations, complications, and knowledge, quality of life and other psychosocial outcomes for children with type 1 diabetes and their families.A systematic and comprehensive literature review was conducted in 21 electronic databases of medical and health education literature to identify randomized controlled trials (RCTs) and observational studies evaluating the effectiveness of diabetes education.Study selection, quality assessment, and data extraction were conducted independently by several investigators in duplicate. A descriptive analysis is presented.From 12,756 citations, 80 studies were identified and included in the review (53 RCTs or CCTs, 27 observational studies). The methodological quality of studies was generally low. Most studies (35/52) that examined the effect of educational interventions on HbA1c found no evidence of increased effectiveness of the interventions over the education provided as part of standard care. Successful interventions were heterogeneous and included cognitive behavioral therapy, family therapy, skills training and general diabetes education. Most studies reported a positive effect on health service utilization (i.e., reduced use), although less than half were statistically significant. There was no clear evidence that educational interventions had an effect on short-term complications. The effect of educational interventions on diabetes knowledge was unclear with 12/30 studies reporting a significant improvement. Interventions which had varying effects on knowledge scores included diabetes camp, general diabetes education, and cognitive behavioral therapy. In the area of self management/regimen adherence, 10/21 studies reported improving this outcome significantly. Successful interventions included general diabetes education and cognitive behavioral therapy. Educational interventions were successful in improving various psychosocial outcomes. The results of two studies examining refinements to intensive therapy education suggest that educational interventions may enhance the effects of intensive diabetes management in reducing HbA1c. CONCLUSIONS Due to the heterogeneity of reported diabetes education interventions, outcome measures, and duration of followup, there is insufficient evidence to identify a particular intervention that is more effective than standard care to improve diabetes control or quality of life or to reduce short-term complications.