Relationship of Children's Emotional and Behavioral Disorders With Health Care Utilization and Missed School

ObjectiveTo assess the association between emotional and behavioral disorders (EBD), missed school days and health care visits while controlling for sociodemographic factors, and comorbid medical conditions in a nationally representative sample.MethodsData from the 2016 National Health Interview Survey were used to assess the associations between EBD, in children aged 4 to 11 and 12 to 17 years, on missed days of school, health care office visits, and emergency department visits. EBD was assessed utilizing a validated screener. Multiple logistic regression was used to control for comorbid medical conditions and sociodemographic factors.ResultsAdolescents who screened positive for anxiety, depression, peer problems, and severe impairment had 4 to 8 times the odds of missing more school than their peers that screened negative. Young children with anxiety had 4 times increased odds of missing more school whereas positive emotional and behavioral health was protective against missing school. Young children and adolescents who screened positive for anxiety, depression, and severe impairment had 3 to 6 and 2 to 4 times the odds of more office visits respectively. Emergency department utilization was significantly increased in adolescents with anxiety and younger children with severe impairment.ConclusionsThis study shows that children with EBD are more likely to have increased office visits and missed days of school, even after adjusting for sociodemographic factors and comorbid medical conditions. Recognition of early associations of EBD can create an opportunity for early identification of children with EBD in the pediatric practice.     

Differences in Frequency of Visits to Pediatric Primary Care Practices and Emergency Departments by Body Mass Index

ObjectivesTo examine differences in utilization across health care settings among children by body mass index (BMI) categories to help identify opportunities for interventions.MethodsA retrospective study was conducted using 1 year of electronic health records following an index primary care visit for children 3 to 17 years old in 2016. Index visits occurred at >40 pediatric practices affiliated with a Northeastern health system. Using normal BMI as a reference group, we examined the extent to which children's BMI percentile categories were associated with primary care visits, emergency department (ED) visits, hospitalizations, and ED visit acuity. Age, sex, race/ethnicity, and insurance status were used as covariates.ResultsOf those with biologically plausible values for height and weight (n = 30,352), the prevalences of overweight, obesity, and severe obesity were 16.3%, 12.4%, and 5.7%, respectively. Children outside of the normal BMI range made more primary care visits; however, relative patterns of ED utilization were not consistent. Children with obesity versus normal BMI were less likely to have ED visits of high acuity. Risk of hospitalization was higher among children with overweight or severe obesity.ConclusionsChildren's BMI categories were associated with health care utilization, specifically primary care visits, ED visits, and hospitalizations. Further investigation is needed to explore the drivers of these differences in utilization, such as the impact of stigma and perceived weight bias on care-seeking patterns, and to examine the role of settings outside of primary care in pediatric weight management.     

Secular trends of blood pressure and body size in a multi-ethnic adolescent population: 1986 to 1996.

OBJECTIVES: To determine the levels and time trends of blood pressure and body size in a healthy population of youth. STUDY DESIGN: Minneapolis, Minnesota, fifth through eighth grade public school children (aged 10 to 14 years) were surveyed in 1986 and 1996. Blood pressure, height, and weight were measured by technicians trained to the same rigorous protocol at each time period, and comparisons were made between the 2 groups (1986 and 1996). RESULTS: In 1986 and 1996, 8222 and 10,241 children, respectively, were measured with participation rates of over 93%. African American, Hispanic, Native American, Asian, and non-Hispanic white groups were all represented. Systolic blood pressure was significantly higher and diastolic blood pressure lower in 1996 than in 1986 in all ethnic and gender groups. Weight and body mass index (wt/ht2) were significantly higher in all groups in 1996. Adjustment for body size largely eliminated the systolic blood pressure differences but had no effect on measured diastolic blood pressure. CONCLUSIONS: Body size and systolic blood pressure are rising among school children. Weight and body mass index show substantial increases over 10 years (1986-1996). Diastolic blood pressure fell for unclear reasons. These changes may have future health implications for cardiovascular disease, as these youth move into adulthood.     

Improving students' diabetes management through school-based diabetes care.

INTRODUCTION: The purpose of this pilot study was to conduct periodic diabetes care visits in school, with the goal of promoting optimal management of diabetes for high-risk youth. METHOD: A convenience sample of 27 students receiving care at a university-affiliated children's diabetes center and enrolled in a large urban school district received the diabetes visit intervention. Intervention effect was measured by parent survey of home/school diabetes management practices, the Self-Efficacy for Diabetes Tool, and a diabetes care-provider survey of subjects' usual care, management competence, and glycemic control. RESULTS: The frequency of diabetes care office visits, insulin adjustment, and home and school blood sugar monitoring all increased. The percentage of children receiving insulin in school doubled. Pre-intervention to post-intervention changes in glycemic control and student self-efficacy did not reach statistical significance. The response to the program was universally positive. DISCUSSION: This study demonstrated that diabetes care visits in school are feasible and not disruptive to the students' educational program. The visits improved diabetes management at home and at school. School nurses' knowledge about diabetes and confidence in diabetes management was improved through a role-modeling approach.     

The prevalence and health care use of overweight children in an integrated health care system

OBJECTIVE: To determine the prevalence, health care use, and costs of overweight children when compared with healthy-weight children. DESIGN: Longitudinal cohort. SETTING: Kaiser Permanente Colorado is an integrated, nonprofit health care system. Patients Eleven thousand six hundred thirty-six children who completed at least 1 body mass index (calculated as weight in kilograms divided by height in meters squared) assessment between 2000 and 2004. MAIN EXPOSURE: Overweight. MAIN OUTCOME MEASURE: Health care use. Based on previous research that demonstrated a higher cost for obese adults when compared with healthy-weight adults, we hypothesized that, when compared with healthy-weight children, overweight children would have higher health care use patterns. RESULTS: Thirteen percent and 14% of the sample, respectively, were classified as overweight or at risk of becoming overweight. At both year 1 (rate ratio [RR] = 1.11 [95% confidence interval (CI), 1.06-1.17]) and year 3 (RR = 1.06 [95% CI, 1.01-1.11]), overweight children had significantly more internal Kaiser Permanente Colorado medical visits, although the magnitude of the relationship was relatively small. Of particular note was the relationship between being overweight and increased use of mental health resources at both points (year 1 RR = 1.47; year 3 RR = 1.48). The calculated additional annual cost of use for 1000 overweight children (regression adjusted to control for comorbidities) was approximately $42 000 for primary care sick visits and $32 000 for mental health visits. CONCLUSION: There is potential for cost savings or cost realignment with weight-management interventions from dollars that could be saved through the reduction of childhood overweight.     

Classroom Temperatures and Asthma-Related School-Based Health Care Utilization: An Exploratory Study

ObjectiveSchools with aging infrastructure may expose students to extreme temperatures. Extreme outdoor temperatures have previously been linked to more asthma-related health care utilization. Explore the relationship between classroom temperatures and school-based health care visits for asthma in an urban school building with an outdated heating and cooling system.MethodsParticipants were students in grades K-8 who received health care from a school-based health center (SBHC) (n = 647) or school nurse (n = 1244) in 2 co-located urban public schools between 2016 and 2018. The probability of an asthma visit to the SBHC or school nurse was modeled as a function of indoor temperature exposure using generalized estimating equations with covariates accounting for grade, sex, outdoor temperature, days at risk of asthma visit, nonasthma visits, month, and year fixed effects.ResultsClassroom temperatures ranged from 48.0?F to 100.6°F. Higher mean grade-level indoor temperatures from a baseline of approximately 70?F to 76?F were associated with increased rates of asthma-related visits to the SBHC or school nurse on same day of exposure. Model-generated estimates suggest that an increase of 10?F in indoor temperature relative to a baseline of 75?F was associated with a 53% increase in the rate of asthma-related SBHC visits.ConclusionsElevated classroom temperatures may be associated with more school-based health care utilization for asthma. Low-income and students from racial and ethnic minority groups have disproportionately higher rates of asthma and are also more likely to attend schools with poor infrastructure. The potential benefits of school infrastructure investments for student health, health care costs, and health equity merit further investigation.     

贵阳市7～17岁少年儿童体质指数分布及超重肥胖状况

目的 了解贵阳市少年儿童体质指数分布及超重、肥胖状况,为儿童营养健康教育提供依据.方法 采用整群随机抽样的方法抽取贵阳市7所中、小学7～17岁的8 616名学生为研究对象,测量身高、体重,计算出体质指数百分位数值.以国际生命科学会中国肥胖问题工作组(WGOC)颁布的"中国学龄儿童青少年超重、肥胖筛查体质量指数值分类标准",对贵阳市少年儿童超重、肥胖状况进行筛查.结果 与WGOC采用的以体质指数P85和P95作为超重和肥胖筛查标准相比,贵阳市男孩P85、P95值均有相对增高趋势,而女孩P85、P95值变化相对不明显;贵阳市少年儿童超重和肥胖总检出率为12.5%和6.8%,其中男孩分别为15.0%和8.4%,女孩分别为9.9%和5.2%,男孩超重、肥胖检出率均高于女孩(P均<0.01).结论 贵阳市超重肥胖儿童日益增多,应重视对儿童超重、肥胖的预防工作.     

Characteristics of eighth-grade students who initiate self-care in elementary and junior high school

The purpose of this paper is to examine whether children who care for themselves for longer periods of time are at increased risk of poor grades, truancy, anger, family conflict, stress, risk-taking, and peer influences (in addition to the increased risk of substance use previously reported). Demographic characteristics of eighth-grade students who initiate self-care in junior high school are compared with those initiating self-care in elementary school. Further, increased risks for those initiating self-care in elementary school are examined. Over two thirds of the respondents (67.8%) cared for themselves after school without adult supervision at some time during the week; 23.5% for 1 to 4 hours per week, 15.7% for 5 to 10 hours per week, and 28.6% for 11 or more hours per week. Of those in self-care, 48.5% initiated self-care during elementary school and 51.5% during junior high school. Students who were in the highest category of self-care (greater than or equal to 11 hours per week) vs those in self-care zero hours per week were 1.5 to 2 times as likely to score high on risk-taking, anger, family conflict, and stress, to be more likely to see their friends as their major source of influence, and to attend more parties. The self-reports of academic grades did not differ. The grade of initiation of self-care (elementary vs junior high school) conferred additional risk for drinking alcohol (odds ratio = 1.4), risk-taking tendencies (odds ratio = 1.5), and attending parties (odds ratio = 1.6).     

Long term health implications of fitness and physical activity patterns.

Northern Ireland has the highest incidence of coronary heart disease (CHD) in the world. The physical fitness, activity patterns, health knowledge, attitudes, and dietary habits of a random, stratified sample of 3211 Northern Irish children, comprising 1540 boys and 1671 girls, age range 11-18 years were examined. At all ages boys were significantly more active than girls. The most important finding was an appreciable decline in physical activity levels after the age of 14 years reaching extremely low levels in older girls. While 75% of exercise taken was not related to school, physical education classes constituted the only exercise taken by one third of pupils. Girls had healthier nutritional habits and were more inclined to employ weight control measures than boys. There was a preponderance of children with a higher body mass index indicating a tendency to obesity in the child population. Over 20% of school leavers of both sexes regularly smoked cigarettes and 20% regularly drank alcohol. The postulated relationship between childhood inactivity, adult sedentary lifestyle, and increased risk of CHD raises serious cause for concern regarding the future cardiovascular health of many children.     

Can a pediatrician effectively treat a 9-year-old obese girl?

CASE:: Maria is a 9-year-old Latina girl who was followed up by her pediatrician since birth with normal developmental milestones, good school achievement, and without significant medical problems. She was not in the pediatric office for the past 3 years. At the age of 9 years, she presented for a health supervision visit. Her pediatrician looked at her growth chart-90 pounds (95th percentile) and height 52 inches (50th percentile)-that confirmed a clinical impression of obesity on physical examination. Her body mass index was 23.4 (>95th percentile for age).During 10 years in primary care pediatric practice, the pediatrician typically prescribed a management plan for obese school-aged and adolescent patients that started with parent and child education about potential health problems associated with obesity followed by a recommendation to decrease the caloric intake and encourage active exercise each day. She then arranged for follow-up visits to monitor weight and adherence to the management plan. However, a moment of self-refection suggested that most of her patients did not follow her advice in a sustained way. Obesity persisted in most cases. The pediatrician wondered if there was an alternative-better yet, evidence-based-approach to pediatric obesity that might provide a better outcome.     

Medical Home and Pediatric Primary Care Utilization Among Children With Special Health Care Needs

IntroductionThe medical home model seeks to improve health care delivery by enhancing primary care. This study examined the relationship between the presence of a medical home and pediatric primary care office visits by children with special health care needs (CSHCN) using the data from 2005-2006 National Survey of Children with Special Healthcare Needs.MethodSurvey logistic regression was used to analyze the relationship.ResultsWhen CSHCN age, gender, ethnicity/race, functional status, insurance status, household education, residence, and income were included in the model, CSHCN with a medical home were 1.6 times more likely to have six or more annual pediatric primary care office visits than were children without a medical home [odds ratio = 1.60, 95% confidence interval = (1.47, 1.75)]. Female CSHCN, younger CSHCN, children with public health insurance, children with severe functional limitations, and CSHCN living in rural areas also were more likely to have a larger number of visits.DiscussionBy controlling for child sociodemographic characteristics, this study provides empirical evidence about how medical home availability affects primary care utilization by CSHCN.     

Which physicians are providing health care to America's children? Trends and changes during the past 20 years

BACKGROUND: Although pediatricians and family physicians are trained in the care of children, previous studies have revealed significant differences in the medical care and specialty referral patterns each provides. During the 1990s, several developments in the population and the health care system (eg, aging of the population and increases in Medicaid managed care) may have resulted in changes to the proportion of children seeking care from one or the other specialty. OBJECTIVE: To determine any changes in the proportion of office visits for children from birth through the age of 17 years provided by pediatricians or family physicians from 1980 to 2000. DESIGN: Analysis of the National Ambulatory Medical Care Survey data sets from 1980 to 2000. During our years of interest, the total number of visits sampled ranged from 2524 to 9151. Visits were analyzed for physician type and patient age. RESULTS: There have been marked changes in the proportion of office visits to general pediatricians vs family physicians during the 1990s. Overall, the percentage of all nonsurgical physician office visits for children from birth through the age of 17 years made to general pediatricians increased significantly, from 56.2% in 1990 to 64.2% in 2000 (P<.001). During the same period, the percentage of all nonsurgical physician office visits for children from birth through the age of 17 years made to family physicians declined significantly, from 33.7% in 1990 to 23.9% in 2000 (P<.001). Visits to pediatric specialists, as a proportion of all visits, increased significantly, from 1.6% in 1980 to 4.5% in 2000 (P<.001). CONCLUSIONS: Pediatricians are providing more primary care visits for children in the United States, and this trend has accelerated during the past 5 years. These findings have implications for the cost of care, the physician workforce, and the training of future physicians. It is unknown if these changes have had a positive or negative impact on the health of our nation's children.     

Resource utilization and expenditures for overweight and obese children

OBJECTIVES: To compare health care utilization and expenditures for healthy-weight patients, overweight patients, and patients with diagnosed and undiagnosed obesity and to examine factors associated with a diagnosis of obesity. DESIGN: Retrospective study using claims data from a large pediatric integrated delivery system. SETTING: An urban academic children's hospital. PARTICIPANTS: Children aged 5 to 18 years who presented to a primary care clinic for well-child care visits during the calendar years 2002 and 2003 and who were followed up for 12 months. MAIN OUTCOME MEASURES: Diagnosis of obesity, primary care visits, emergency department visits, laboratory use, and health care charges. RESULTS: Of 8404 patients, 57.9% were 10 years or older, 61.2% were African American, and 72.9% were insured by Medicaid. According to the criteria of body mass index (calculated as weight in kilograms divided by the square of height in meters), 17.8% were overweight and 21.9% were obese. Of the obese children, 42.9% had a diagnosis of obesity. Increased laboratory use was found in both children with diagnosed obesity (odds ratio [OR], 5.49; 95% confidence interval [CI], 4.65-6.48) and children with undiagnosed obesity (OR, 2.32; 95% CI, 1.97-2.74), relative to the healthy-weight group. Health care expenditures were significantly higher for children with diagnosed obesity (adjusted mean difference, $172; 95% CI, $138-$206) vs the healthy-weight group. Factors associated with the diagnosis of obesity were age 10 years and older (OR, 2.7; 95% CI, 2.0-3.4), female sex (OR, 1.5; 95% CI, 1.2-1.8), and having Medicaid (OR, 1.6; 95% CI, 1.1-2.3). CONCLUSIONS: Increased health care utilization and charges reported in obese adults are also present in obese children. Most children with obesity had not been diagnosed as having obesity in this administrative data set.     

Weight charts and well-child care: how the pediatrician became the expert in child health.

Weighing children became popular in the 1910s, when public health workers hoped to identify malnourished children based on weight. They measured tens of thousands of children in school halls and church basements, compared their results with standard weight charts, and reported evidence of widespread malnutrition. In the 1920s, physicians argued that a complete medical history and a physical examination, not just weight, were necessary to diagnose malnutrition. By the 1930s, the weight chart had become merely one of the many diagnostic tools used to monitor the health of well children in the physician's office. Weight charts remain an essential part of pediatric practice, but their history is more than a simple tale of scientific progress. This article explores how pediatrics emerged as a primary care specialty in the midst of conflict over the meaning of weight, the professional role of women in medicine, and the pediatrician's preeminence as a child health expert.     

Overweight does not increase asthma risk but may decrease allergy risk at school age after infantile bronchiolitis

Aim: Increasing evidence suggests that overweight children are at increased risk of asthma. The association between weight gain and allergy is more complex. The aim was to evaluate the association between overweight or obesity and asthma, allergy, bronchial reactivity or atopic sensitization at school age in children with bronchiolitis in infancy. Subjects and methods: Eighty‐one children hospitalized for bronchiolitis at <24 months of age attended control visits at 7.2 and 12.3 years of ages. The visits consisted of medical examinations, weight and height measurements, body mass index (BMI) calculations, skin prick tests and exercise challenge tests. BMI >1.3 SD from age‐ and gender‐specific references meant overweight and BMI >2.0 SD obesity. Results: Current or previous overweight or obesity did not increase the risk of asthma, allergy, bronchial reactivity or atopic sensitization at 7.2 or 12.3 years of age. Previous and current obesity decreased the risk of atopic dermatitis, and current overweight and obesity decreased the risk of sensitization to outdoor allergens at 12.3 years of age. Conclusion: Previous or current overweight does not increase asthma or allergy risk but current obesity may decrease allergy risk at school age after bronchiolitis in infancy.     

Somatic growth of lean children: the potential role of sleep

Background

Despite the current obesity pandemic, childhood malnutrition remains an urgent, public health concern. Similar to the obesity pandemic, childhood malnutrition is influenced by genetic and a number of social, environmental and biological factors. In this study, we investigated the association between sleep duration and somatic growth in lean children.

Methods

A stratified, randomly clustered sampling design was used to select fifth grade students from 10 primary schools in Shanghai. Based on a body mass index below the 15th percentile a subsample of 143 lean children aged 10–11 years old was defined. Sleep duration and other potential confounders were surveyed through parental or self-report questionnaires. Body measurements were collected and used to calculate the Z score of weight, height, body mass index as well as body fat percentage.

Results

Compared with children who slept <9 hours, those who slept for ≥10 hours grew taller and gained more weight after adjusting for confounding factors. When children slept 9–10 hours, they had significantly higher Z score of weight and body mass index.

Conclusions

Prolonged sleep not only benefits weight gain but also improves height in lean children. Our findings might provide important public health advice such that prolonged sleep may be an effective modifier of nutritional problems in childhood.     

Adolescents' Perception of Asthma Symptoms and Health Care Utilization

Introduction

Pediatric asthma is accountable for a substantial use of health care services. The purpose of this study was to systemically examine the extent to which inaccurate perception of asthma symptoms is associated with the use of health care services.

Methods

This exploratory study included 126 adolescents with asthma who were between 13 and 20 years of age. Subjects were classified as having inaccurate symptom perception (IG); well-controlled accurate symptom perception (WCA); and poorly controlled accurate symptom perception (PCA). These groups were compared with respect to health care utilization, including emergency department (ED) visits, hospitalization, and office visits and school absenteeism in the past 3 months.

Results

More adolescents in the IG group had at least one hospitalization compared with adolescents in the PCA or WCA groups (23.1% vs. 11.1% vs. 2.6%, respectively). A similar trend was seen for ED visits. Compared with the WCA group, adolescents in the IG group were nearly nine times more likely to have been hospitalized, 3.4 times more likely to have visited an ED, and four times more likely to have missed school days.

Discussion

Adolescents with inaccurate symptom perception are more likely to have hospitalizations, ED visits, and missed days from school compared with those who have accurate perceptions. The findings underscore the importance of screening for perceptual accuracy of asthma symptoms and call for interventions promoting accurate symptom assessment in adolescents with asthma to ensure appropriate care.     

Dissatisfactioin with height and weight,and attempts at height gain and weight control in Korean school-children

Most students are reported to be dissatisfied with their height and weight. The current study was designed to assess the prevalence of height and weight dissatisfaction and specific height-gain and weight-control attempts in school-children in Korea. A questionnaire survey was carried out in 3,382 students aged 11-18 years. The prevalence of dissatisfaction with height and weight was significantly higher in girls than in boys. High school students were more dissatisfied with their height and weight than elementary school students. The concordance rates between perceived vs actual height and weight were 30% and 45%, respectively. The average desired adult height was 8-9 cm taller than the average Korean adult height. The average desired adult weight was 4.9 kg more in boys, and 4.8 kg less in girls, than the current average Korean adult weight. Approximately 4.4-7.3% of overall school-children had tried to promote their growth. The prevalence of height-gain attempts was highest in middle school students, and the prevalence of weight-control attempts was highest in high school students. Among the height-gain methods, herbal medicine was most frequently used (46.4%), followed by growth-promoting health supplements (27.4%) and growth hormone (3.2%). For weight control, exercise at a fitness center was more favored (54.5%) than herbal medicine (17.5%) or diet drugs (13.0%). In conclusion, the prevalence of height and weight dissatisfaction was high and many students made attempts at height gain and weight control. These data emphasize the importance of health education about body image to students.