Jeffrey A. Wright

Early Adiposity Rebound and the Risk of Adult Obesity

Objective. At 5 to 6 years of age, body fatness normally declines to a minimum, a point called adiposity rebound (AR), before increasing again into adulthood. We determined whether a younger age at AR was associated with an increased risk of adult obesity and whether this risk was independent of fatness at AR and parent obesity. Design. A retrospective cohort study using lifelong height and weight measurements recorded in outpatient medical records. Setting. Group Health Cooperative of Puget Sound (GHC), a health maintenance organization based in Seattle, Washington. Participants. All 390 GHC members (and their parents) born at GHC between January 1, 1965, and January 1, 1971, who had at least one recorded adult height and weight measurement plus two visits with recorded height and weight measurements in each of three age intervals: 1.5 to 4, 4 to 8, and 8 to 16 years. Main Outcome Measures. We calculated the mean body mass index (BMI) of each subject during young adulthood (age 21 to 29 years) and the BMI of the parents when each subject was 1.5 years of age. Adult obesity was defined as a BMI ≥27.8 for males and ≥27.3 for females. Curves were fit to each subjects BMI values between ages 1.5 and 16 years, and the age and BMI at AR were calculated from these curves. Subjects were divided into tertiles of age at AR (early, middle, and late), BMI at AR, and parent BMI (heavy, medium, and lean). Results. The mean age at AR was 5.5 years, and 15% of the cohort was obese in young adulthood. Adult obesity rates were higher in those with early versus late AR (25% vs 5%), those who were heavy versus lean at AR (24% vs 4%), those with heavy versus lean mothers (25% vs 5%), and those with heavy versus lean fathers (21% vs 5%). After adjusting for parent BMI and BMI at AR, the odds ratio for adult obesity associated with early versus late AR was 6.0 (95% CI, 1.3–26.6). Conclusion. An early AR is associated with an increased risk of adult obesity independent of parent obesity and the BMI at AR. Future research should examine the biological and behavioral determinants of AR.

Is greater continuity of care associated with less emergency department utilization

Background. The benefits of continuity of care (COC) have not been firmly established for pediatric patients. Objective. To assess whether greater COC is associated with lower emergency department (ED) utilization. Setting. Outpatient teaching clinic at Childrens Hospital and Regional Medical Center, Seattle, WA. Patients. All 785 Medicaid managed care children ages 0 to 19 years followed at Childrens Hospital and Regional Medical Center between 1993 to 1997 who had at least four outpatient visits. Methods. Retrospective claims-based analysis. COC was quantified based on the number of different care providers in relation to the number of clinic visits. Results. Attending COC was significantly greater than resident COC. In a multiple event survival analysis, compared with those patients in the lowest tertile of attending COC, those in the middle tertile had 30% lower ED utilization (hazard ratio 0.70 [0.53–0.93]) and those in the highest tertile had 35% lower ED use (hazard ratio 0.65 [0.50–0.80]). Resident COC was not significantly associated with ED use. Conclusion. Greater COC with attending physicians in outpatient teaching clinics is associated with lower ED utilization.

The association between greater continuity of care and timely measles-mumps-rubella vaccination.

OBJECTIVES This study assessed whether greater continuity of care is associated with timely administration of measles-mumps-rubella (MMR) vaccination. METHODS We studied 11,233 patients continuously enrolled in Group Health Cooperative (GHC) from birth to 15 months. We used a preestablished index to quantify continuity of care based on the number of primary care providers in relation to the number of clinic visits. MMR vaccination status at 15 months was assessed with automated immunization data systems at GHC. RESULTS In a logistic regression model, both medium continuity (odds ratio [OR] = 1.20, 95% confidence interval [CI] = 1.08, 1.33) and high continuity (OR = 1.36, 95% CI = 1.22, 1.52) were associated with increased likelihood of being immunized by 15 months compared with patients in the lowest tercile of continuity of care. CONCLUSION Greater continuity of care is associated with more timely immunization.

Attentional dysfunction in children with encopresis

ABSTRACT. Encopresis and attentional dysfunction are common neurobehavioral disorders of childhood. The extent to which these disorders occur in association is unknown. The purpose of this study is to document the comorbidity of attentional dysfunction in a clinically identified population of encopresis patients. We used the Child Behavior Checklist (CBCL) to estimate the prevalence of disordered attention or hyperactivity in a group of children with encopresis seen at a tertiary care facility. Responses to CBCL questionnaires were analyzed to compare scores on the “hyperactive‘’ behavior subscale with published normative data. The number of encopretic respondents with T scores above 70 (<2 SD above the mean) on a hyperactivity subscale was ascertained for each age and gender cohort. From 347 eligible new clinic patients, responses from 167 were suitable for analysis. Overall, 23.4% of children with encopresis (95% confidence interval: 17.2%–30.5%) had T scores on the hyperactive subscale higher than 70. This prevalence (ten fold greater than expected in the normal population) was similar in both genders and across age groups. This association between attentional dysfunction and encopresis has significance for theories regarding etiology and for practical treatment strategies. J Dev Behav Pediatr 14:381–385, 1993. Index terms: attention deficit disorder, encopresis, comorbidity, Child Behavior Checklist.

Randomized intervention to increase children's selection of low-fat foods in school lunches

OBJECTIVE The purpose of this study was to determine whether children would increase their selection of low-fat foods in school lunches if these foods were labeled on the menu and parents were notified of their availability. METHODS The 16 elementary schools in the Bellevue (Washington) School District were randomly assigned to intervention and control groups. Participants were the students eating the school lunch--an average of 2445 students per day, of whom one third received free or reduced-price lunches. In all schools, one of the two daily lunch entrees was low in fat (< or = 30% of calories from fat). After a 5-month baseline period, eight schools received a 4-month intervention. The monthly menus carried home by students began to indicate the low-fat entree and to compare the fat content of both entrees. In the first month, parents in the intervention schools (2329 households) received a mailing with a copy of the menu, an informational pamphlet on dietary fat, and a letter that described the menu changes and asked the parents to encourage their children to select low-fat entrees. A follow-up telephone survey was performed in one school 1 month after the intervention mailing to assess the recall and impact of the intervention. The main outcome, based on 249,861 student meal selections, was the proportion of students who selected the low-fat entree, and the unit of analysis was the school. RESULTS At baseline, there was little difference between intervention and control schools in the percentage of children choosing the low-fat entree (31.5% vs 30.8%). During the intervention, there was an increase in low-fat entree selection in the intervention schools compared with the control schools (35.5% vs 32.2%; p = 0.03). Of 221 parents surveyed, 71% recalled the mailing, 53% remembered that there were now low-fat entrees on the menu, and 10% reported that, after the mailing, they asked their child to choose a low-fat entree.

A Trade-Off Analysis of Routine Newborn Circumcision

BACKGROUND The risks associated with newborn circumcision have not been as extensively evaluated as the benefits. OBJECTIVES The goals of this study were threefold: 1) to derive a population-based complication rate for newborn circumcision; 2) to calculate the number needed to harm for newborn circumcision based on this rate; and 3) to establish trade-offs based on our complication rates and published estimates of the benefits of circumcision including the prevention of urinary tract infections and penile cancer. METHODS Using the Comprehensive Hospital Abstract Reporting System for Washington State, we retrospectively examined routine newborn circumcisions performed over 9 years (1987-1996). We used International Classification of Diseases, Ninth Revision codes to identify both circumcisions and complications and limited our analyses to children without other surgical procedures performed during their initial birth hospitalization. RESULTS Of 354, 297 male infants born during the study period, 130,475 (37%) were circumcised during their newborn stay. Overall 287 (.2%) of circumcised children and 33 (.01%) of uncircumcised children had complications potentially associated with circumcision coded as a discharge diagnosis. Based on our findings, a complication can be expected in 1 out every 476 circumcisions. Six urinary tract infections can be prevented for every complication endured and almost 2 complications can be expected for every case of penile cancer prevented. CONCLUSIONS Circumcision remains a relatively safe procedure. However, for some parents, the risks we report may outweigh the potential benefits. This information may help parents seeking guidance to make an informed decision.

Infant Video Viewing and Salivary Cortisol Responses: A Randomized Experiment

OBJECTIVE To test the hypothesis that salivary cortisol levels respond differently when infants play with blocks compared with watching a digital video disk (DVD). STUDY DESIGN We conducted a randomized experiment in which 8- to 14-month-old infants either watched a DVD or played with blocks for 30 minutes. Serial salivary cortisol measurements were obtained and analyzed, and parental and infant responses and activities were recorded. Results were converted to standardized effect sizes (ESs) for clarity of presentation. RESULTS A total of 49 infants (49% female, mean age 10.6 months) participated in the study. In linear regression analyses, there was a trend toward higher cortisol levels in the block group at the 35-minute collection point (ES = 0.47, P = .08) and significantly higher levels at 45 minutes (ES = 0.56, P = .04); these salivary cortisol levels reflect serum levels approximately 10 and 20 minutes into the activity period, respectively. The results were substantially the same in sensitivity analyses excluding the outliers. CONCLUSION Viewing by infants of a DVD leads to different neuroendocrine responses than block play in a laboratory setting. The implications of these differences are currently unknown, but may suggest different means of cognitive engagement between interactive play and DVD viewing.

Newborn Nursery Care

The care of a normal newborn is a balance between providing interventions to prevent disease and screening to allow for the early identification of rare conditions while facilitating maternal-infant bonding and promotion of feeding. Ideally, evidence-based interventions and monitoring of the newborn infant should be provided as unobtrusively as possible. In this chapter we examine the evidence surrounding the most commonly recommended interventions, screening, monitoring, assessment and counseling of new parents. Normal and abnormal adaptation to extrauterine life including vital signs, temperature regulation, weight loss, stool and urine patterns and glucose homeostasis are described, and suggested management of newborns with common prenatal ultrasound findings is provided. The evidence for the benefits of interventions such as intramuscular vitamin K, newborn metabolic, hearing and pulse oximetry screening is weighed against their potential risks. For controversial topics such as male circumcision, balanced information is provided that can be used by clinicians for discussions with parents. Finally, two of the central concerns during the newborn stay are jaundice and possible sepsis. While clinicians are most concerned with under diagnosis of either condition, the effects of over treatment are not insignificant. The evidence underlying recommended guidelines for these conditions is evaluated, and methods for screening for jaundice and sepsis that limit testing and treatment while maximizing the chance of identifying newborns with either condition are offered.

Is Increased Continuity of Care Associated with Decreased Er Utilization Rates in Children? † 622

Is Increased Continuity of Care Associated with Decreased Er Utilization Rates in Children? † 622