Callie L. Brown

Addressing Childhood Obesity: Opportunities for Prevention

The overweight and obesity epidemic among children and adolescents in the United States continues to worsen, with notable racial, ethnic, and socioeconomic disparities. Risk factors for pediatric obesity include genetics; environmental and neighborhood factors; increased intake of sugar-sweetened beverages (SSBs), fast-food, and processed snacks; decreased physical activity; shorter sleep duration; and increased personal, prenatal, or family stress. Pediatricians can help prevent obesity by measuring body mass index at least yearly and providing age- and development-appropriate anticipatory guidance to families. Public policies and environmental interventions aim to make it easier for children to make healthy nutrition and physical activity choices. Interventions focused on family habits and parenting strategies have also been successful at preventing or treating childhood obesity.

Behaviors and motivations for weight loss in children and adolescents

To examine the association between weight loss behaviors and motivations for weight loss in children and adolescents and the association of weight status with these behaviors and motivations in a nationally representative sample.

Family-based obesity treatment in children with disabilities.

OBJECTIVE To assess the relative effectiveness of an interdisciplinary, family-centered, tertiary-care pediatric weight management program for the treatment of patients with and without cognitive disabilities (CD). METHODS Retrospective analysis of the clinical database of a tertiary-care pediatric weight management clinic (n = 453), extracting data from electronic health records including longitudinal change in weight status (body mass index [BMI] z-score) and frequency of attrition from treatment. Upon review of medical records, children enrolled in the treatment program were classified as having no CD (n = 342) or CD (n = 111). RESULTS At baseline, there were no between-group differences in BMI or BMI z-score. After 4 months of treatment, 66% (299) of patients remained enrolled, and complete case data were available for 219 children in final analyses. There were no statistically significant differences in attrition between the 2 groups (no CD vs CD). Mean change in BMI z-score across all groups was -0.03 ± 0.13 (P < .001). Change in BMI z-score was significantly greater among patients with CD (-0.07 ± 0.15) compared to those without CD (-0.03 ± 0.12) (difference 0.04, 95% confidence interval 0.005-0.08, P = .029). These change estimates were observed after adjusting for processes potentially associated with attrition. CONCLUSIONS Children with CD treated in an interdisciplinary, family-centered obesity clinic had similar or better outcomes compared to peers without CD. This success may be attributable to the patient-centered nature of this behavioral weight management program, which focused on leveraging the unique strengths and capabilities of each individual patient and family.

Vision Screening in Children Aged 6 Months to 5 Years: Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance Preschool vision screening could allow detection and treatment of vision abnormalities during a critical developmental stage, preserving function and quality of life. Objective To review the evidence on screening for and treatment of amblyopia, its risk factors, and refractive error in children aged 6 months to 5 years to inform the US Preventive Services Task Force. Data Sources MEDLINE, Cochrane Library, CINAHL, and trial registries through June 2016; references; and experts, with surveillance of the literature through June 7, 2017. Study Selection English-language randomized clinical trials (RCTs) or prospective cohort studies that evaluated screening, studies evaluating test accuracy, RCTs of treatment vs inactive controls, and cohort studies or case-control studies assessing harms. Data Extraction and Synthesis Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings. Studies were not quantitatively pooled because of clinical and methodological heterogeneity. Main Outcomes and Measures Visual acuity, amblyopia, school performance, functioning, quality of life, test accuracy, testability, and harms. Results Forty studies were included (N = 34 709); 34 evaluated test accuracy. No RCTs compared screening with no screening, and no studies evaluated school performance, function, or quality of life. Studies directly assessing earlier or more intensive screening were limited by high attrition. Positive likelihood ratios were between 5 and 10 for amblyopia risk factors or nonamblyogenic refractive error in most studies of test accuracy and were greater than 10 in most studies evaluating combinations of clinical tests. Inability to cooperate may limit use of some tests in children younger than 3 years. Studies with low prevalence (<10%) of vision abnormalities showed high false-positive rates (usually >75%). Among children with amblyopia risk factors (eg, strabismus or anisometropia), patching improved visual acuity of the amblyopic eye by a mean of less than 1 line on a standard chart after 5 to 12 weeks for children pretreated with glasses (2 RCTs, 240 participants); more children treated with patching than with no patching experienced improvement of at least 2 lines (45% vs 21%; P = .003; 1 RCT, 180 participants). Patching plus glasses improved visual acuity by about 1 line after 1 year (0.11 logMAR [95% CI, 0.05-0.17]) for children not pretreated with glasses (1 RCT, 177 participants). Glasses alone improved visual acuity by less than 1 line after 1 year (0.08 logMAR [95% CI, 0.02-0.15], 1 RCT, 177 participants). Conclusions and Relevance Studies directly evaluating the effectiveness of screening were limited and do not establish whether vision screening in preschool children is better than no screening. Indirect evidence supports the utility of multiple screening tests for identifying preschool children at higher risk for vision problems and the effectiveness of some treatments for improving visual acuity outcomes.

Association of Picky Eating With Weight Status and Dietary Quality Among Low-Income Preschoolers

BACKGROUND Picky eating is common in children. Few studies have examined predictors of picky eating, and the association of picky eating with weight status and dietary quality is inconsistent in the literature. We aimed to identify predictors of picky eating and to test the association of picky eating with child body mass index z-score (BMIz), dietary quality, and micronutrient intake. METHODS This was a cross-sectional analysis of baseline data from a randomized controlled trial to prevent obesity among 506 preschoolers attending Head Start. Parents completed questionnaires to assess picky eating and child temperament. Three 24-hour dietary recalls were collected to assess dietary intake. Multivariate regression models assessed child, parent, and family predictors of picky eating; additional models tested adjusted associations of picky eating with child BMIz, dietary quality (measured using the Healthy Eating Index-2010), and micronutrient intake. RESULTS Picky eating was predicted by male sex, older child age, and more difficult temperament but not race/ethnicity, maternal body mass index, maternal depressive symptoms, household food insecurity, or single parent home. Picky eating was not associated with child BMIz or micronutrient deficiencies; it was inversely associated with total Healthy Eating Index-2010 score and servings of whole fruit, total vegetables, greens and beans, and total protein foods. CONCLUSIONS Pediatric providers should support parents in expanding the number of healthy foods the child eats to improve dietary quality, but reassure parents that picky eating is not associated with childrens weight status or micronutrient deficiencies.

Chronic Cough and Bilateral Pulmonary Infiltrates in a Previously Healthy Adolescent Male

A previously healthy 11-year-old Caucasian male presented to our emergency department with a chief complaint of fever, shortness of breath, and fatigue. He had been unwell for 3 months, with intermittent fevers to 102°F, dry cough, malaise, loss of appetite, and a 10-pound weight loss. Two months prior to presentation, he was seen at an outside emergency department where a chest x-ray was performed and was normal. During the course of his illness, he was seen twice by his pediatrician, and received 2 empiric courses of oral antibiotics (amoxicillin clavulanate and cefdinir) for presumed community-acquired pneumonia with no clinical improvement; no chest x-ray was obtained. After completing a 10 day course of amoxicillin clavulanate and a 14-day course of cefdinir, he was afebrile for 3-4 days, although he continued to have persistent cough and fatigue. Prior to presentation, his fever had recurred, accompanied by dyspnea and severe fatigue. He denied any recent travel or exposure to pets but endorsed a hobby of chopping down trees and also helped his father load and spread the mulch. On examination, he appeared comfortable but was febrile (102.2°F) with a heart rate of 97 beats per minute, respiratory rate of 21 breaths per minute, blood pressure of 92/57 mm Hg, and an oxygen saturation of 95% on room air. Chest auscultation was clear bilaterally with a normal work of breathing. The remainder of his physical examination was normal. Laboratory evaluation was significant for a white blood cell count of 21.7 cells/mm (with 80% neutrophils, 9% lymphocytes, 7% monocytes, and 4% eosinophils), hemoglobin of 14.2 g/ dL, and platelet count of 264 000 cells/mm. Serum lactic dehydrogenase and uric acid were normal. A monospot test was negative and a respiratory virus panel was positive for rhinovirus/enterovirus by polymerase chain reaction. A blood culture obtained on admission was negative. A chest x-ray showed bilateral airspace opacities, worse in the left upper and right middle lobes, and a small right pleural effusion (Figure 1). While admitted, he continued to have daily fevers to 102°F to 104°F. A purified protein derivative was negative. On hospital day 3, a repeat blood culture was obtained and was negative. Pulmonology, Allergy/ Immunology, and Infectious Disease services were consulted and recommendations included obtaining a chest computed tomography (CT) scan, diagnostic bronchoscopy, immune evaluation, and starting empiric vancomycin and ceftriaxone. A CT scan of the chest with contrast demonstrated diffuse multifocal areas of bronchiectasis and dense airspace opacities, near total atelectasis of the right middle lobe, diffuse mediastinal and bilateral hilar adenopathy, and tiny loculated pleural effusions (Figure 2). On hospital day 4, a flexible bronchoscopy with bronchoalveolar lavage (BAL) was performed, which revealed the underlying diagnosis.