Treating childhood obesity in primary care

The objective of this prospective, cohort study was to assess an intervention for obese children (9-12 years of age) and their families delivered in primary care. A family-based, behavioral weight management program consisted of 11 sessions. The treatment consisted of a calorie goal, self-monitoring of daily food intake, physical activity and sedentary behavior, and other behavior change skills. A total of 78 children and families entered treatment; 23 children served as quasi-controls. The mean weight loss at 15 weeks among 55 children (71%) who completed the program was 2.4 lbs (SD = 5.24, range of -16.7 to +8.4 lbs) compared with a mean weight gain of 3.45 lbs (SD = 4.31, range of -5.0 to +12.0 lbs) among 23 control children. The mean change in body mass index z score from baseline to month 24 was -0.17 ± 0.32 (P < .001). Primary care is an appropriate place to identify and treat children with obesity.     

The foster care clinic: a community program to identify treatment needs of children in foster care

A community-based multiagency and multidisciplinary clinic was developed to perform comprehensive evaluations of preschool children in foster care. One hundred thirteen children, ages 1 month to 6 years old, were seen during the first 2 years. Forty-seven percent of the children were known to the social service agency from birth; however, the mean age at placement was 19 months. Fifty-seven percent of the children were in their first foster home at the time of their initial evaluation, but 17% has already been placed in three or more homes. Behavioral problems were found in 39% of the children, and chronic medical problems in 35%. Sixty-one percent of the children were delayed in one or more portions of the developmental assessment. Developmental delay was associated with older age. Sixty percent of the children with developmental delays were not involved in any community educational or therapeutic program, although they had been in foster care for a mean of 6 months. Because of the high mobility of this population, continuity of care by social workers, foster parents, and physicians is hard to achieve. The evaluation model developed by the clinic appears to facilitate the identification of children in need of additional services, enhances cooperation between various community agencies, and provides a constant site for monitoring the status and progress of children in foster care.     

YMCA program for childhood obesity: a case series

Family-based behavioral interventions for treatment of childhood obesity have rarely been tested for effectiveness in community settings. The aim of the study was to evaluate the effectiveness of a community-based program for obese children designed to stabilize or reduce body weight. Obese children from our pediatric practice who were active in the program were evaluated. Weight gain during the time of the study was compared with mean weight gain for a group of obese-matched controls who did not participate in the program. Mean weight gain for subjects was 0.28 kg/mo compared with a weight gain for controls of 0.62 kg/mo. Between the first and last visits, 43% (15/35) of the subjects experienced clinically significant differences in weight gain compared with controls. Eight patients lost weight. A YMCA weight management program, which included group counseling, nutrition education, physical activity, and gift card incentives, resulted in favorable changes in overweight children.     

Parental obesity and higher pre-intervention BMI reduce the likelihood of a multidisciplinary childhood obesity program to succeed--a clinical observation

OBJECTIVE: To assess the effects and identify factors associated with success of a combined, structured multidisciplinary weight management program in obese children and adolescents. METHODS: Seventy-seven obese children (age 6-16 years) participated in a 12-month combined dietary-behavioral-exercise intervention. Thirty-seven (age and maturity comparable) obese children who did not participate in the structured program served as controls. Body weight, BMI, and BMI percentiles were measured at baseline, after 6 months, and at the end of the intervention. RESULTS: The combined intervention was associated with a significant decrease in BMI (from 25.9+/-0.4 to 24.5+/-0.4 kg/m2, p <0.0005) and BMI percentile (from 97.3+/-0.2% to 92.6+/-0.9%, p <0.0005). In contrast, obese children who did not participate in the structured program gained weight (from 51.4+/-3.6 to 57.7+/-3.7 kg, p <0.0005), increased their BMI (from 25.2+/-1.0 to 26.6+/-0.9 kg/m2, p <0.0005), and had a non-significant increase in BMI percentiles (from 94.9+/-0.8% to 95.4+/-0.9%, NS). Children with higher BMI percentiles and parental overweight tended to respond less favorably to the combined multidisciplinary program (p <0.01). CONCLUSIONS: A prolonged (12 mo), combined, structured multidisciplinary intervention for childhood obesity resulted in a significant decrease in BMI and BMI percentiles. Higher pre-intervention BMI percentiles and parental obesity were associated with less favorable responses to the combined intervention.     

The effectiveness of a primary care-based pediatric obesity program

The objective of this retrospective cohort study was to evaluate the effectiveness of the Duke University Healthy Lifestyles Program (HLP), a primary care-based childhood obesity treatment program. The study population included obese 2- through 19-year-old patients who entered the HLP between October 2006 through December 2008 and who had a visit to the HLP between the sixth and eighth month after entry. Most of the 282 patients were female (57%) and non-Hispanic/non-White (61%). The median age was 11 years. At baseline, the mean body mass index standard deviation score (BMI SDS) was 2.51, and patients achieved a mean reduction in BMI SDS of 0.10 (standard deviation = 0.20). For patients with baseline and follow-up measures of comorbidities, there were improvements in blood pressure, triglycerides, total cholesterol, and insulin resistance (P < .05). The patients in our obesity program demonstrated a small reduction in the severity of obesity. Improvements occurred in some obesity-associated comorbidities.     

Headache in pediatric and neuropsychiatric primary care. A pilot study

BACKGROUND: To evaluate the prevalence of headache in primary health care for children (child neuropsychiatry and pediatric primary care), detecting possible differences among areas, showing the number of patients with headache with a clinical significance that had not been communicated to a physician and studying the clinical features of cases. METHODS: A questionnaire is administered to all consecutive patients of 3 child neuropsychiatrists of a primary health care unit during a period of 20 days and of 2 family pediatricians during a period of 10 days. Data are collected on 259 children, between 5 and 14 years. RESULTS: 17.76% of examined children have recurrent headache. The percentage is significantly different (p < 0.05) in neuropsychiatry (22.78%) and pediatrics (9.90%). 63.04% of parents with children affected by headache have never reported the disease to a physician and 28.26% of affected children should follow a preventive therapy, but do not. Among all children, 6.56% have migraine and 8.49% have a tension-type headache, according to ICD-10 criteria. CONCLUSIONS: The higher frequency of headache in child neuropsychiatric primary care is probably due to a comorbidity with psychiatric diseases. The high number of non-reported cases of headache is in agreement with data reported in the literature about adults and suggests that it is important to ask standard questions about headache in the course of the anamnesis in all primary health care for children.     

Does a residents' continuity clinic provide primary care?

Pediatric residents are required to care for a group of children over a period of time. For many, this "continuity" experience is in a hospital outpatient department that may or may not provide primary care. We applied a measure of primary care to the Primary Care Clinic, the continuity clinic at The Johns Hopkins Hospital, Baltimore, Md, and found that it compared favorably with private pediatric practices in the Baltimore area, providing significantly more "principal care" (93% vs. 84.5% of encounters), and to the Harris Lane Home walk-in clinic, where only 51% of encounters were "principal care". The Primary Care Clinic scored higher on a primary care index, a measure of the extent to which the facility serves as a primary care source for patients, suggesting that hospital-based training can provide residents with an opportunity to provide primary care.     

Parasitology screening of Latin American children in a primary care clinic.

A screening program based in a Massachusetts community hospital primary care clinic, which included 124 children from 12 different Latin American countries, demonstrated that nearly 35% were carriers of pathogenic parasites. The large majority (83.7%) of these children were asymptomatic at the time of the examination. Although there may be considerable variation based on country of origin, the present results, as well as a review of the literature, suggest this is likely to be a common finding among children born in most regions of Latin America. Compliance with the screening process was significantly higher in groups with higher infection rates and the successive yield in those patients who submitted two or more stool samples revealed that most pathogens were identified in the first sample. School-age children were found to have the highest risk for both roundworm infections and multiple parasitic infections. For those children with identified pathogens, nearly 90% received treatment. Current trends in immigration, international adoptions, and special circumstances including day care, family shelters, and increasing numbers of human immunodeficiency virus-infected children have made an appreciation of the extent of parasitosis, and awareness of possible management approaches, an important consideration for primary care physicians in the United States.     

Training pediatric residents in a primary care clinic to help address psychosocial problems and prevent child maltreatment

ObjectiveThe objectives of this study were to determine whether 1) residents trained in the SEEK (A Safe Environment for Every Kid) model would report improved attitudes, knowledge, comfort, competence, and practice regarding screening for psychosocial risk factors (parental depression, parental substance abuse, intimate partner violence, stress, corporal punishment, and food insecurity); 2) intervention residents would be more likely to screen for and assess those risk factors; and 3) families seen by intervention residents would report improved satisfaction with their child’s doctor compared to families receiving standard care from control residents.MethodsPediatric residents in a university-based pediatrics continuity clinic were enrolled onto a randomized controlled trial of the SEEK model. The model included resident training about psychosocial risk factors, a Parent Screening Questionnaire, and a study social worker. Outcome measures included: 1) residents’ baseline, 6-month, and 18-month posttraining surveys, 2) medical record review, and 3) parents’ satisfaction regarding doctor-parent interaction.ResultsNinety-five residents participated. In 4 of 6 risk areas, intervention residents scored higher on the self-assessment compared to control subjects, with sustained improvement at 18 months. Intervention residents were more likely than control subjects to screen and assess parents for targeted risk factors. Parents seen by intervention residents responded favorably regarding interactions with their doctor.ConclusionsThe SEEK model helped residents become more comfortable and competent in screening for and addressing psychosocial risk factors. The benefits were sustained. Parents viewed the intervention doctors favorably. The model shows promise as a way of helping address major psychosocial problems in pediatric primary care.     

A protocolized approach to identify and manage hyperglycemia in a pediatric critical care unit

INTRODUCTION: Hyperglycemia is a risk factor for poor outcome in critically ill patients, and glycemic control may decrease morbidity and mortality in adults. There is limited information regarding hyperglycemia and its control in pediatric intensive care. OBJECTIVE: To determine prevalence and risk factors for hyperglycemia and evaluate our approach to glycemic control in critically ill children. DESIGN, SETTING, PATIENTS, AND MAIN OUTCOMES: A pediatric-specific protocol to identify and manage hyperglycemia was developed and instituted as standard practice in our pediatric intensive care unit, and was applicable to patients >6 months and >5 kg, without end-stage liver disease or type 1 diabetes mellitus. Triggers for routine blood glucose assessment were based on supportive measures including mechanical ventilation, vasopressor/inotrope infusions, and antihypertensive infusions. Hyperglycemic patients, defined by two consecutive blood glucose readings of >140 mg/dL (7.7 mmol/L), were treated with infused insulin to maintain blood glucose levels 80-140 mg/dL (4.4-7.7 mmol/L). We performed retrospective analysis 6 months after instituting this approach. Main outcomes were prevalence and risk factors for hyperglycemia, and effectiveness of our approach to achieve glycemic control. INTERVENTIONS: None. MEASUREMENTS/MAIN RESULTS: One hundred forty-five of 477 patients had blood glucose actively assessed, and 74 developed hyperglycemia and were managed with insulin. This approach to identify patients with hyperglycemia had a positive predictive value of 51% and negative predictive value of 94%. Hyperglycemia prevalence was 20%. Mechanical ventilation, vasopressor/inotropic infusion, continuous renal replacement therapy, high illness severity scores, and longer lengths of stay were associated with hyperglycemia. The average blood glucose of patients with hyperglycemia was 200 mg/dL (11 mmol/L), and on average, patients were treated with insulin for 6.3 days with 2.4 units/kg/day. Blood glucose levels were <160 mg/dL (8.8 mmol/L) in 70% of insulin-treated days, 80-140 mg/dL (4.4-7.7 mmol/L) in 49% of insulin-treated days, and 4% of insulin-treated patients had any blood glucose measurements <40 mg/dL (2.2 mmol/L). CONCLUSIONS: Hyperglycemia is prevalent in pediatric intensive care units and may be effectively identified and managed using a protocolized approach.     

The academic children's hospital primary care clinic: responding to the challenges of a changing health care environment

Academic medical centers have encountered increasing fiscal challenges as the paradigm in health care has shifted from traditional fee-for-service reimbursement to systems of managed care. Most academic centers have maintained primary care clinics, which have served as "educational laboratories" for students and trainees. Largely providing care to underserved patients, academic primary care clinics have been heavily dependent on Medicaid reimbursement for support. Given the realities of a rapidly changing health care environment, academic primary care clinics have been challenged to respond with innovation and creativity in order to remain viable. The pediatric primary care clinic at Rainbow Babies & Children's Hospital of University Hospitals of Cleveland initiated a reorganization program with the goal of ensuring that patients receive quality, cost efficient care and that students and pediatric residents receive first-rate ambulatory education in a fiscally responsible setting. Fundamental was the setting of priorities for patient care and service while promoting an environment conducive to medical education. Educational programs were segregated into a well-defined educational "module," and various initiatives were advanced emphasizing patient access, consistency of care, efficient use of space and personnel resources, limitation of inappropriate use of costly after-hours resources, and identification and coordination of care for patients with chronic illness and/or at high risk for medical complications. Three years after the instituting of fundamental organizational change, objective measures of cost efficiency and selected quality measures compare quite favorably with a broad range of primary care providers throughout the region. If academic medical centers are to remain leaders in ambulatory pediatric education, energetic, proactive, and thoughtful responses to the rapidly changing global health care environment will be necessary.     

Behavioral counselling to prevent childhood obesity - study protocol of a pragmatic trial in maternity and child health care

ABSTRACT: BACKGROUND: To report protocol of a pragmatic lifestyle intervention aiming to primary prevention of childhood obesity. METHODS: A non-randomized controlled pragmatic trial in maternity and child health care clinics. The control group was recruited among families who visited the same clinics one year earlier. Eligibility criteria was mother at risk for gestational diabetes: body mass index [greater than or equal to] 25 kg/m2, macrosomic newborn in any previous pregnancy, immediate family history of diabetes and/or age [greater than or equal to] 40 years. All maternity clinics in town involved in recruitment. The gestational intervention consisted of individual counselling on diet and physical activity by a public health nurse, and of two group counselling sessions. Intervention continues until offspring's age of five years. An option to participate a group counselling at child's age 1 to 2 years was offered. The intervention includes advice on healthy diet, physical activity, sedentary behavior and sleeping pattern. The main outcome measure is offspring BMI z-score and its changes at the age of six years. CONCLUSION: Early childhood is a critical time period for prevention of obesity. Pragmatic trials targeting this period are necessary in order to find effective obesity prevention programs feasible in normal health care practice.