Joanne E. Cox

Prevalence of Vitamin D Deficiency Among Healthy Infants and Toddlers

OBJECTIVES To determine the prevalence of vitamin D deficiency and to examine whether 25-hydroxyvitamin D (25OHD) concentration varies as a function of skin pigmentation, season, sun exposure, breastfeeding, and vitamin D supplementation. DESIGN Cross-sectional sample. SETTING Urban primary care clinic. PARTICIPANTS Healthy infants and toddlers (N = 380) who were seen for a routine health visit. OUTCOME MEASURES Primary outcomes were serum 25OHD and parathyroid hormone levels; secondary measures included data on sun exposure, nutrition, skin pigmentation, and parental health habits. Wrist and knee radiographs were obtained for vitamin D-deficient participants. RESULTS The prevalence of vitamin D deficiency (< or =20 ng/mL) was 12.1% (44 of 365 participants), and 146 participants (40.0%) had levels below an accepted optimal threshold (< or =30 ng/mL). The prevalence did not vary between infants and toddlers or by skin pigmentation. There was an inverse correlation between serum 25OHD and parathyroid hormone levels (infants: r = -0.27, P < .001; toddlers: r = -0.20, P = .02). In multivariable models, breastfeeding without supplementation among infants and lower milk intake among toddlers were significant predictors of vitamin D deficiency. In vitamin D-deficient participants, 3 participants (7.5%) exhibited rachitic changes on radiographs, whereas 13 (32.5%) had evidence of demineralization. CONCLUSIONS Suboptimal vitamin D status is common among otherwise healthy young children. Predictors of vitamin D status vary in infants vs toddlers, information that is important to consider in the care of these young patients. One-third of vitamin D-deficient participants exhibited demineralization, highlighting the deleterious skeletal effects of this condition.

Treatment of Hypovitaminosis D in Infants and Toddlers

CONTEXT Hypovitaminosis D appears to be on the rise in young children, with implications for skeletal and overall health. OBJECTIVE The objective of the study was to compare the safety and efficacy of vitamin D2 daily, vitamin D2 weekly, and vitamin D3 daily, combined with supplemental calcium, in raising serum 25-hydroxyvitamin D [25(OH)D] and lowering PTH concentrations. DESIGN This was a 6-wk randomized controlled trial. SETTING The study was conducted at an urban pediatric clinic in Boston. SUBJECTS Forty otherwise healthy infants and toddlers with hypovitaminosis D [25(OH)D < 20 ng/ml] participated in the study. INTERVENTIONS Participants were assigned to one of three regimens: 2,000 IU oral vitamin D2 daily, 50,000 IU vitamin D2 weekly, or 2,000 IU vitamin D3 daily. Each was also prescribed elemental calcium (50 mg/kg.d). Infants received treatment for 6 wk. MAIN OUTCOME MEASURES Before and after treatment, serum measurements of 25(OH)D, PTH, calcium, and alkaline phosphatase were taken. RESULTS All treatments approximately tripled the 25(OH)D concentration. Preplanned comparisons were nonsignificant: daily vitamin D2 vs. weekly vitamin D2 (12% difference in effect, P = 0.66) and daily D2 vs. daily D3 (7%, P = 0.82). The mean serum calcium change was small and similar in the three groups. There was no significant difference in PTH suppression. CONCLUSIONS Short-term vitamin D2 2,000 IU daily, vitamin D2 50,000 IU weekly, or vitamin D3 2,000 IU daily yield equivalent outcomes in the treatment of hypovitaminosis D among young children. Therefore, pediatric providers can individualize the treatment regimen for a given patient to ensure compliance, given that no difference in efficacy or safety was noted among these three common treatment regimens.

Depression, Parenting Attributes, and Social Support among Adolescent Mothers Attending a Teen Tot Program

OBJECTIVE To investigate the associations between depressive symptoms in adolescent mothers and their perceived maternal caretaking ability and social support. PATIENTS AND METHODS Subjects were participants enrolled in a parenting program that provided comprehensive multidisciplinary medical care to teen mothers and their children. Baseline data of a prospective cohort study were collected by interview at 2 weeks postpartum and follow-up, and standardized measures on entry into postnatal parenting groups. Demographic data included education, social supports, psychological history, family history and adverse life events. Depressive symptoms were measured with the Center for Epidemiological Studies Depression Scale for Children short version (CES-DC). The Maternal Self-report Inventory (MSRI) measured perceived maternal self-esteem, and Duke-UNC Functional Social Support Questionnaire measured social support. Data were analyzed with bivariate analyses and linear regression modeling focusing on depressive symptoms as the outcome variable. RESULTS In the 168 teen mothers, mean age 17.6 +/- 1.2 years, African American (50%), Latina (31%) or Biracial (13%), the prevalence of depressive symptoms was 53.6%. In the linear model, controlling for babys age, teens age, ethnicity, Temporary Aid for Families with Dependent Children (TAFDC), and previous suicidal gesture, increased depressive symptoms were associated with decreased perceived maternal caretaking ability (P = 0.003) and lower social support (P < 0.001). In a linear model controlling for the same variables, MSRI total score (P = 0.001) and social support (P < 0.001) contributed significantly to the model as did the interaction term (MSRI x Social Support, P = 0.044). CONCLUSIONS Depression is associated with decreased maternal confidence in their ability to parent and decreased perceived maternal social support, with a possible moderating effect of social support on the relationship of maternal self-esteem and depression.

Adolescent childbearing: consequences and interventions.

Purpose of review Adolescent childbearing in the United States continues to occur at high rates compared with other industrialized nations, despite a recent decline. Adolescent mothers and their offspring are at risk for negative outcomes. Recent literature exploring the consequences of teenage childbearing and interventions to ameliorate these consequences are presented. Recent findings Negative consequences of adolescent childbearing can impact mothers and their offspring throughout the lifespan. These consequences are likely attributable to social and environmental factors rather than solely to maternal age. Increasing educational attainment, preventing repeat pregnancy and improving mother–child interactions can improve outcomes for mothers and their children. Home, community, school and clinic-based programs are all viable models of service delivery to this population. Summary Connecting teen mothers with comprehensive services to meet their social, economic, health and educational needs can potentially improve long-term outcomes for both mothers and their offspring. Programs that deliver care to this population in culturally sensitive, developmentally appropriate ways have demonstrated success. Future investigation of parenting interventions with larger sample sizes and that assess multiple outcomes will allow comparison among programs. Explorations of the role of the father and coparenting are also directions for future research.

Screening for Social Determinants of Health Among Children and Families Living in Poverty: A Guide for Clinicians

Approximately 20% of all children in the United States live in poverty, which exists in rural, urban, and suburban areas. Thus, all child health clinicians need to be familiar with the effects of poverty on health and to understand associated, preventable, and modifiable social factors that impact health. Social determinants of health are identifiable root causes of medical problems. For children living in poverty, social determinants of health for which clinicians may play a role include the following: child maltreatment, child care and education, family financial support, physical environment, family social support, intimate partner violence, maternal depression and family mental illness, household substance abuse, firearm exposure, and parental health literacy. Children, particularly those living in poverty, exposed to adverse childhood experiences are susceptible to toxic stress and a variety of child and adult health problems, including developmental delay, asthma and heart disease. Despite the detrimental effects of social determinants on health, few child health clinicians routinely address the unmet social and psychosocial factors impacting children and their families during routine primary care visits. Clinicians need tools to screen for social determinants of health and to be familiar with available local and national resources to address these issues. These guidelines provide an overview of social determinants of health impacting children living in poverty and provide clinicians with practical screening tools and resources.

Redesigning Health Care Practices to Address Childhood Poverty

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

Prevalence of Transient Hyperphosphatasemia Among Healthy Infants and Toddlers

OBJECTIVE: To describe the prevalence and clinical characteristics of transient hyperphosphatasemia (TH) in a cohort of healthy infants and toddlers. METHODS: We performed a secondary data analysis of healthy infants and toddlers enrolled in a study examining the epidemiology of vitamin D deficiency. From 2005 to 2007, children aged 8 to 24 months were enrolled during well-child visits at an urban primary care pediatric clinic. At enrollment, we collected data regarding sociodemographic and clinical characteristics. We measured serum levels of alkaline phosphatase (AP), 25-hydroxyvitamin D, parathyroid hormone (PTH), calcium, magnesium, and phosphorus. We placed participants into 1 of 3 categories on the basis of serum AP levels: normal (AP: 110–400 U/L), intermediate (AP: >400 to 1000 U/L), and TH (AP: >1000 U/L). We used Fishers exact test and analysis of variance to evaluate differences in characteristics among the 3 groups. RESULTS: Nine (2.8%) of 316 children had an AP level of >1000 U/L (mean: 2165 U/L). Sixteen children (5.1%) had an intermediate serum AP level (mean: 544 U/L). Mean weight-for-age, length-for-age, and weight-for-length z scores were similar across all 3 AP groups. Compared with the 291 children without TH, children in the intermediate AP and TH groups had similar mean serum levels of 25-hydroxyvitamin D, PTH, calcium, magnesium, and phosphorus. CONCLUSIONS: TH seems to be a relatively common condition among healthy infants and toddlers. TH was not associated with anthropometric measures, vitamin D status, PTH, or serum minerals. Recognition of this benign condition is important to avoid unnecessary investigations.

Teen pregnancy prevention: current perspectives.

Purpose of review Teen pregnancy has been subject of public concern for many years. In the United States, despite nearly 2 decades of declining teen pregnancy and birth rates, the problem persists, with significant disparities present across racial groups and in state-specific rates. This review examines recent trends, pregnancy prevention initiatives and family planning policies that address the special needs of vulnerable youth. Recent findings Unintended teen pregnancies impose potentially serious social and health burdens on teen parents and their children, as well as costs to society. Trends in teen pregnancy and birth rates show continued decline, but state and racial disparities have widened. Demographic factors and policy changes have contributed to these disparities. Research supports comprehensive pregnancy prevention initiatives that are multifaceted and promote consistent and correct use of effective methods of contraception for youth at risk of becoming pregnant. Summary There is strong consensus that effective teen pregnancy prevention strategies should be multifaceted, focusing on delay of sexual activity especially in younger teens while promoting consistent and correct use of effective methods of contraception for those youth who are or plan to be sexually active. There is a need for further research to identify effective interventions for vulnerable populations.

Determinants of Health and Pediatric Primary Care Practices

More than 20% of children nationally live in poverty. Pediatric primary care practices are critical points-of-contact for these patients and their families. Practices must consider risks that are rooted in poverty as they determine how to best deliver family-centered care and move toward action on the social determinants of health. The Practice-Level Care Delivery Subgroup of the Academic Pediatric Association’s Task Force on Poverty has developed a roadmap for pediatric providers and practices to use as they adopt clinical practice redesign strategies aimed at mitigating poverty’s negative impact on child health and well-being. The present article describes how care structures and processes can be altered in ways that align with the needs of families living in poverty. Attention is paid to both facilitators of and barriers to successful redesign strategies. We also illustrate how such a roadmap can be adapted by practices depending on the degree of patient need and the availability of practice resources devoted to intervening on the social determinants of health. In addition, ways in which practices can advocate for families in their communities and nationally are identified. Finally, given the relative dearth of evidence for many poverty-focused interventions in primary care, areas that would benefit from more in-depth study are considered. Such a focus is especially relevant as practices consider how they can best help families mitigate the impact of poverty-related risks in ways that promote long-term health and well-being for children.

Current treatment approaches to overweight in adolescents

Purpose of review The prevalence of overweight among adolescents aged 12 to 19 in the United States has steadily increased since the 1960s. The purpose of this review is to familiarize primary care clinicians with the most recent primary care, pharmacotherapy, and surgical options for the treatment of overweight in adolescence. Recent findings Initial treatment of the overweight adolescent should involve a comprehensive approach that facilitates changes in diet, exercise, and behavior that engage the entire family as participants and role models. For adolescents in whom a comprehensive program of diet, exercise, and behavior modification is unsuccessful, referral to a multidisciplinary team to explore further options, which may include medication and bariatric surgery, should be considered. Experience with medication for use in weight loss and bariatric surgery in adolescents is limited. Currently, two medications, orlistat and sibutramine, have been approved by the United States Food and Drug Administration for long-term use in adolescents. Bariatric surgery is currently recommended only for adolescents who are severely overweight (body mass index ≥40) and have comorbid conditions. This intervention should be considered only after failure of other comprehensive interventions and intense medical and psychologic evaluation by a specialty referral center. Summary More research is needed to clarify the roles and timing of diet, exercise, behavior modification, pharmacotherapy, and surgical intervention. Also, long-term studies are needed to further determine the benefits and risks of pharmacotherapy and bariatric surgery in adolescents.