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Carson V, Zhang Z, Boyd M, Potter M, Li J, Kuzik N, Hunter S. Moderators of movement behaviour changes among Canadian toddlers and preschoolers throughout the first 2 years of the COVID-19 pandemic. Appl Physiol Nutr Metab 2024; 49:1228-1240. [PMID: 38815592 DOI: 10.1139/apnm-2023-0453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Primary objectives were to examine: (1) changes in movement behaviours (i.e., outdoor play (OP), organized physical activity (PA), screen time (ST), sleep) across the first 2 years of coronavirus disease-2019 (COVID-19) among Canadian toddlers and preschoolers, and (2) intrapersonal, interpersonal, community, and policy moderators of change in movement behaviors. Participants were 341 Canadian parents of children (start of study: 1-4 years; 48% female). Participants completed online questionnaires regarding their children's movement behaviours and intrapersonal, interpersonal, and community factors at five time-points before and throughout the pandemic (T1-T5). Data from government websites were also used for some community and policy factors. Linear mixed models were conducted. Compared to pre-COVID-19 (T1): OP was on average 30 min/day higher at T2 and T3; organized PA was on average 62, 44, and 37 min/day lower at T2, T3, and T4, respectively; ST was on average 67, 17, 38, and 52 min/day higher at T2, T3, T4, and T5, respectively; and sleep was on average 30, 36, and 82 min/day lower at T3, T4, and T5, respectively. Significant moderating variables were observed for OP (parental education, parental work inside home, COVID-19 restriction severity), organized PA (children's sex, started kindergarten, nonparental care, parental education, household income, parental employment status, house type, indoor home space and support for PA), ST (nonparental care, parental marital status) and sleep (children's T1 age group, started kindergarten, parental place of birth, parental employment status). All movement behaviors changed across the first 2 years of COVID-19 but patterns and moderators were behaviour-specific. Children from lower socioeconomic status families had the least optimal patterns.
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Affiliation(s)
- Valerie Carson
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada
| | - Zhiguang Zhang
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada
- School of Health and Society, University of Wollongong, Wollongong, NSW, Australia
| | - Madison Boyd
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada
| | - Morgan Potter
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada
| | - Joshua Li
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada
| | - Nicholas Kuzik
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada
- Children's Hospital of Eastern Ontario - Research Institute, Ottawa, ON, Canada
| | - Stephen Hunter
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
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Lum M, Yoong SL, Wolfenden L, Turon H, Reilly K, Grady A. Impact of a dissemination strategy on family day care educators' intentions to adopt outdoor free play guidelines introduced in response to COVID-19: a randomized controlled trial. HEALTH EDUCATION RESEARCH 2023; 38:458-468. [PMID: 36943373 PMCID: PMC10516333 DOI: 10.1093/her/cyad014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/02/2023] [Accepted: 03/06/2023] [Indexed: 06/18/2023]
Abstract
In 2021, guidelines for early childhood education and care were released recommending children are provided access to outdoor areas during all free play sessions to reduce the risk of coronavirus disease of 2019 transmission, aligning with the existing recommendations to increase children's physical activity. There is a need to understand how to disseminate guidelines in this setting as dissemination is a prerequisite of adoption and implementation. This randomized controlled trial explored the impact of a video-based strategy to disseminate guidelines on family day care educators' intentions to adopt outdoor free play guidelines. Educators (N = 255) were randomized to receive a video (intervention) or text-based (usual care) resource via email describing recommendations. Educators were invited to participate in a post-intervention survey at 5-week follow-up assessing intentions to adopt guidelines. The secondary outcomes included knowledge, beliefs about capabilities, beliefs about consequences, social/professional role and identity, goals, implementation of guidelines, acceptability of resource and intervention reach. There was no statistically significant difference between groups in intentions to adopt guidelines [ß = 0.01 (95% confidence interval -0.50 to 0.52), P = 0.97], nor for any secondary outcomes. Further investigation is needed to identify effective dissemination strategies in the family day care setting to increase the adoption of public health guidelines.
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Affiliation(s)
- M Lum
- Hunter New England Population Health, Hunter New England Local Health District, Booth Building, Longworth Ave, Wallsend, NSW 2287, Australia
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Cct, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
| | - S L Yoong
- Hunter New England Population Health, Hunter New England Local Health District, Booth Building, Longworth Ave, Wallsend, NSW 2287, Australia
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Cct, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
- Global Centre for Preventive Nutrition and Health, Institute for Health Transformation, School of Health and Social Development, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia
| | - L Wolfenden
- Hunter New England Population Health, Hunter New England Local Health District, Booth Building, Longworth Ave, Wallsend, NSW 2287, Australia
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Cct, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
| | - H Turon
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Cct, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
| | - K Reilly
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Cct, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
| | - A Grady
- Hunter New England Population Health, Hunter New England Local Health District, Booth Building, Longworth Ave, Wallsend, NSW 2287, Australia
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Cct, New Lambton Heights, NSW 2305, Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
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Liu J, Wyver S, Chutiyami M, Little H. Outdoor Time, Space, and Restrictions Imposed on Children's Play in Australian Early Childhood Education and Care Settings during the COVID Pandemic: A Cross-Sectional Survey from Educators' Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6779. [PMID: 37754638 PMCID: PMC10530731 DOI: 10.3390/ijerph20186779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023]
Abstract
The study aimed to investigate the impact of COVID-19 restrictions on children's access to the outdoors in early childhood education and care (ECEC) settings. An online survey comprised of a standardised scale and questions used in previous related studies was completed by 143 early childhood educators across Australia. Participants were asked to report children's time spent outdoors, access to outdoor space, and restrictions imposed on children's play during the pandemic compared to the pre-pandemic period. The survey responses were imported into SPSS for descriptive, correlation, and ordinal regression analyses. We examined the relationship between children's outdoor time, space, restrictions imposed on children's play, and educators' characteristics, such as qualifications, professional development, and tolerance of risk or staff-child ratios during the pandemic in Australia. Most educators reported that children's outdoor time and access to outdoor space remained the same compared to before the pandemic, while imposed restrictions on children's outdoor play increased. The results of ordinal regressions indicated that educators with a higher tolerance of risk were less likely to impose additional restrictions on children's outdoor play. The findings contribute to the understanding of how educators' tolerance of risk influences children's outdoor play opportunities and provide directions for future risk-reframing interventions.
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Affiliation(s)
- Junjie Liu
- Macquarie School of Education, Macquarie University, Sydney, NSW 2109, Australia; (S.W.); (M.C.); (H.L.)
| | - Shirley Wyver
- Macquarie School of Education, Macquarie University, Sydney, NSW 2109, Australia; (S.W.); (M.C.); (H.L.)
| | - Muhammad Chutiyami
- Macquarie School of Education, Macquarie University, Sydney, NSW 2109, Australia; (S.W.); (M.C.); (H.L.)
- School of Nursing and Midwifery, Faculty of Health, University of Technology Sydney, Sydney, NSW 2007, Australia
| | - Helen Little
- Macquarie School of Education, Macquarie University, Sydney, NSW 2109, Australia; (S.W.); (M.C.); (H.L.)
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Hwang Y, Boyd M, Davenport C, Carson V. The Relative Contributions of Center Demographic, Director, Parental, Social, Environmental, and Policy Factors to Changes in Outdoor Play in Childcare Centers During the COVID-19 Pandemic. J Phys Act Health 2023; 20:508-521. [PMID: 37055024 DOI: 10.1123/jpah.2022-0408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 01/04/2023] [Accepted: 02/05/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND The primary objective of this study was to investigate the relative contributions of factors from multiple social-ecological levels in explaining outdoor play changes in childcare centers during the COVID-19 pandemic. METHODS In Alberta, Canada, licensed childcare center directors (n = 160) completed an online questionnaire. For outcomes, changes in the frequency and duration of outdoor play in childcare centers during COVID-19 compared to before COVID-19 were measured. For exposures, center demographic, director, parental, social, environmental, and policy-level factors were measured. Hierarchical regression analyses were conducted separately for winter (December-March) and nonwinter months (April-November). RESULTS In most instances, factors at each social-ecological level explained a statistically significant amount of unique variance in changes in outdoor play in childcare centers during COVID-19. Full models accounted for more than 26% of the variance in the outcomes. Changes in parental interest in outdoor play was the most consistent correlate of changes in the frequency and duration of outdoor play in both winter and nonwinter months during COVID-19. In terms of changes in the duration of outdoor play, social support from the provincial government, health authority, and licensing, and changes in the number of play areas in licensed outdoor play spaces were also consistent correlates in both winter and nonwinter months during COVID-19. CONCLUSIONS Factors from multiple social-ecological levels uniquely contributed to changes in outdoor play in childcare centers during the COVID-19 pandemic. Findings can help inform interventions and public health initiatives related to outdoor play in childcare centers during and after the ongoing pandemic.
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Affiliation(s)
- Yeongho Hwang
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB,Canada
| | - Madison Boyd
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB,Canada
| | - Cody Davenport
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB,Canada
| | - Valerie Carson
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB,Canada
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Carson V, Zhang Z, Kuzik N, Adamo KB, Predy M, Crozier M, Hunter S, Ogden N, Goldfield GS, Okely AD. The impact of new government childcare accreditation standards on children's in-care physical activity and sedentary time. BMC Public Health 2022; 22:616. [PMID: 35351049 PMCID: PMC8966317 DOI: 10.1186/s12889-022-12888-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 03/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A new physical activity and sedentary behaviour accreditation standard criterion for childcare settings was introduced by the provincial government in Alberta, Canada. The primary objective of this study was to examine if changes for in-care physical activity and sedentary time (ST) differed between centres in and around Edmonton, Alberta after implementing the new accreditation standards and non-accredited control centres in and around Ottawa, Ontario. Secondary objectives were to examine whether baseline age group (toddler, preschooler) or the childcare environment moderated any group differences in change of the primary outcomes. Furthermore, accreditation and control group differences in change of children's body mass index (BMI) Z-scores or cognitive development as well as educators' perceptions of the primary outcomes were explored. METHODS Participants were 252 toddlers (19-35 months) and preschoolers (36-60 months) in childcare centres from Alberta (n = 11) and Ontario (n = 8) in the supporting Healthy physical AcTive CHildcare setting (HATCH) study. In-care ST, light-intensity physical activity (LPA), and moderate- to vigorous-intensity physical activity (MVPA) were accelerometer-derived before and 6 months after the implementation of the new standards. At both time points, cognitive development (working memory, expressive vocabulary), heights, and weights were measured, and BMI Z-scores were calculated. Additionally, the childcare environment was observed using the Environment and Policy Assessment and Observation (EPAO) and Movement Environment Rating Scale (MOVERS) tools. Demographic characteristics were parent-reported and weather variables were derived from Environment Canada data. Mixed models were conducted. RESULTS In adjusted models (n = 241), change in children's in-care ST (B = -0.07, 95%CI: - 1.43,1.29), LPA (B = 0.08, 95%CI: - 0.89,1.05), and log-transformed MVPA (B = 0.01, 95%CI: - 0.09,0.11) were not significantly different between accreditation and control groups. Age group and the childcare environment were not moderators. Significant increases in BMI Z-score (B = 0.19, 95%CI: 0.03,0.35) and high working memory (OR = 3.24, 95%CI: 1.32,7.97) were observed in the accreditation group and significant increases in expressive vocabulary (B = 3.18, 95%CI: 0.05,6.30) were observed in the control group. CONCLUSIONS The new accreditation criterion may not significantly change physical activity or ST in childcare settings and therefore may not explain findings for BMI Z-scores and cognitive development. Additional training and resources may be needed.
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Affiliation(s)
- Valerie Carson
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada.
| | - Zhiguang Zhang
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada
| | - Nicholas Kuzik
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada
| | - Kristi B Adamo
- Faculty of Health Science, University of Ottawa, Ottawa, ON, Canada
| | - Madison Predy
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada
| | - Mitchell Crozier
- Faculty of Health Science, University of Ottawa, Ottawa, ON, Canada
| | - Stephen Hunter
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB, Canada
| | - Nancy Ogden
- Faculty of Arts, Mount Royal University, Calgary, AB, Canada
| | - Gary S Goldfield
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Anthony D Okely
- Early Start and Illawarra Health and Medical Research Institute, Faculty of Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW, Australia
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Carson V, Predy M, Hunter S, Storey K, Farmer AP, McIsaac JL, Flynn J. An Environmental Scan of Existing Canadian Childcare Resources Targeting Improvements in Health Behaviours. EARLY CHILDHOOD EDUCATION JOURNAL 2021; 50:1417-1428. [PMID: 36339969 PMCID: PMC9622543 DOI: 10.1007/s10643-021-01266-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/03/2021] [Indexed: 06/16/2023]
Abstract
UNLABELLED The objective was to conduct an environmental scan of existing Canadian childcare resources targeting nutrition, physical activity, sedentary behaviour, and/or sleep. A comprehensive search plan was conducted that involved four search strategies: (1) grey literature databases, (2) customized Google search engines, (3) targeted websites, and (4) consultation with content experts. A resource (i.e., information, materials) must have been created by government or an organization/agency within Canada, available in English, intended for childcare educators or directors working with children ≤ 5 years of age, and focused on targeting improvements in nutrition, physical activity, sedentary behaviour, and/or sleep. The quality of each included resource was assessed using a modified version of the Authority, Accuracy, Coverage, Objectivity, Date, Significance checklist. A total of 192 eligible resources were included. Most resources targeted only nutrition (n = 101) or physical activity (n = 60), and few resources targeted only sedentary behaviour (n = 2) or sleep (n = 1). The remaining 28 resources targeted more than one health behaviour. The 4 most common topics of resources were menu/meal planning (n = 55), healthy nutrition practices/environment (n = 37), physical activities/games (n = 33), and nutrition/food literacy (n = 20). Only 52 included resources cited evidence. One-third of the included resources (n = 64) were rated as high quality, including 55 that received a point for the significance criterion. Therefore, numerous high quality Canadian childcare resources exist for nutrition and physical activity. Future resource development is needed for sedentary behaviour and sleep. Findings can assist future intervention work and the database of resources can be utilized by relevant stakeholders to support other childcare initiatives. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s10643-021-01266-2.
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Affiliation(s)
- Valerie Carson
- Faculty of Kinesiology, Sport and Recreation, University of Alberta, Edmonton, AB Canada
| | - Madison Predy
- Faculty of Kinesiology, Sport and Recreation, University of Alberta, Edmonton, AB Canada
| | - Stephen Hunter
- Faculty of Kinesiology, Sport and Recreation, University of Alberta, Edmonton, AB Canada
| | - Kate Storey
- School of Public Health, University of Alberta, Edmonton, AB Canada
| | - Anna P. Farmer
- Faculty of Agricultural, Life and Environmental Sciences, University of Alberta, Edmonton, AB Canada
| | - Jessie-Lee McIsaac
- Department of Child and Youth Study, Faculty of Education, Mount Saint Vincent University, Halifax, NS Canada
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Lee EY, Bains A, Hunter S, Ament A, Brazo-Sayavera J, Carson V, Hakimi S, Huang WY, Janssen I, Lee M, Lim H, Silva DAS, Tremblay MS. Systematic review of the correlates of outdoor play and time among children aged 3-12 years. Int J Behav Nutr Phys Act 2021; 18:41. [PMID: 33736668 PMCID: PMC7972019 DOI: 10.1186/s12966-021-01097-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/01/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Due to the myriad of benefits of children's outdoor play and time, there is increasing concern over its decline. This systematic review synthesized evidence on the correlates of outdoor play and outdoor time among children aged 3-12 years. METHODS A total of 12 electronic databases in five different languages (Chinese, English, Korean, Spanish, Portuguese) were searched between October 28, 2019 and July 27, 2020. Covidence software was used for screening and Microsoft Excel with a predesigned coding form was used for data extraction. Evidence was synthesized and correlates were categorized using the socioecological model framework. RESULTS Based on 107 studies representing 188,498 participants and 422 childcare centers from 29 countries, 85 studies examined potential correlates of outdoor play while 23 studies examined that of outdoor time (one examined both). The duration of outdoor play and outdoor time ranged between 60 and 165 min/d and 42-240 min/d, respectively. Out of 287 (outdoor play) and 61 (outdoor time) potential correlates examined, 111 correlates for outdoor play and 33 correlates for outdoor time were identified as significant correlates. Thirty-three variables were identified as key/common correlates of outdoor play/time, including eight correlates at the individual level (e.g., sex/gender, race/ethnicity, physical activity), 10 correlates at the parental level (e.g., parental attitude/support/behavior, parenting practice), nine at the microsystem level (e.g., proximal home/social environment such as residence type, peer influence), three at the macrosystem/community level (e.g., availability of space children can play), and three at the physical ecology/pressure for macrosystem change level (e.g., seasonality, rurality). No key correlates were found at the institutional level. CONCLUSIONS Individual, parental, and proximal physical (home) and social environments appear to play a role in children's outdoor play and time. Ecological factors (i.e., seasonality, rurality) also appear to be related to outdoor play/time. Evidence was either inconsistent or lacking at institutional and macrosystem/community levels. Standardizing terminology and measures of outdoor play/time is warranted. Future work should investigate the interactions and processes of multiple variables across different levels of socioecological modelling to better understand the mechanisms through which outdoor play/time opportunities can be optimized for children while paying special attention to varying conditions in which children are born, live, and play.
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Affiliation(s)
- Eun-Young Lee
- School of Kinesiology and Health Studies, Queen’s University, Kingston, ON Canada
- Department of Gender Studies, Queen’s University, Kingston, ON Canada
| | - Ajaypal Bains
- School of Kinesiology and Health Studies, Queen’s University, Kingston, ON Canada
| | - Stephen Hunter
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Canada
| | - Alyssa Ament
- School of Kinesiology and Health Studies, Queen’s University, Kingston, ON Canada
| | | | - Valerie Carson
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Canada
| | - Shawn Hakimi
- School of Kinesiology and Health Studies, Queen’s University, Kingston, ON Canada
| | - Wendy Y. Huang
- Centre for Health and Exercise Science Research, Department of Sport, Physical Education and Health, Hong Kong Baptist University, Hong Kong, China
| | - Ian Janssen
- School of Kinesiology and Health Studies, Queen’s University, Kingston, ON Canada
- Department of Health Sciences, Queen’s University, Kingston, Canada
| | - Mikyung Lee
- School of Kinesiology and Health Studies, Queen’s University, Kingston, ON Canada
| | - Heejun Lim
- School of Kinesiology and Health Studies, Queen’s University, Kingston, ON Canada
| | | | - Mark S. Tremblay
- Healthy Active Lifestyle and Obesity (HALO) research group, Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
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