Judy A. Theriot

Decreased prevalence of nonalcoholic fatty liver disease in black obese children.

Objectives: Nonalcoholic fatty liver disease (NAFLD) is a common cause of pediatric liver disease. Studies suggest decreased prevalence in blacks, females, and younger children. However, the proportion of black subjects in these studies was small, and children under 12 were not included. We propose that abnormal alanine aminotransferase (ALT) is more common in whites than blacks, males than females, and children over 12 compared with younger children in a prospective study. Methods: We enrolled 181 consecutive asymptomatic obese children attending general pediatric clinics who denied recent fever or known liver disease. Obesity was defined as body mass index (BMI) z score of greater than 1.64 (95th percentile for age and sex). Elevated ALT was defined as greater than 40 U/L. BMI z score, race, sex, age, and parental obesity were compared using the chi-square test and Fishers exact test. Results: The population included 81 males and 100 females, 147 nonHispanic black, 33 nonHispanic white, and 1 Hispanic white. Elevated ALT occurred in 14 (8%) subjects. White children were significantly more likely to have abnormal ALT (odds ratio [OR] = 4.0, P < .02). Very obese children (BMI z score >2.3) were more likely to have abnormal ALT compared with mildly obese children (OR = 4.0, P < 0.05). Sex, age, hepatomegaly, acanthosis nigricans, and parental obesity did not significantly predict elevated ALT. Conclusion: Eight percent of asymptomatic, obese children had an elevated ALT suggestive of NAFLD. White and very obese children are more likely to be affected. Sex and age are not good clinical predictors of NAFLD. We suggest that all obese children be screened for NAFLD.

The Impact of Early Literacy Guidance on Language Skills of 3-Vear-Olds

The objective of this prospective study was to determine the impact of early literacy anticipatory guidance (AG) with provision of books on language development in 3-year-olds in an early literacy program at a University-affiliated inner-city pediatric clinic. The Peabody Picture Vocabulary Test (PPVT-III) and the Expressive One Word Picture Vocabulary Test (EOWPVT-R) were administered to 33-39-month-old children exposed to an early literacy program, which included AG and provision of an age-appropriate book at each well-child visit starting at 2 months old. Children with developmental delays were excluded. Parental surveys on literacy and demographic data were obtained. Univariate and multivariate analyses were performed. Sixty-four children were evaluated; 88% African American, 89% Medicaid recipients. Fifty-eight percent of families reported familycentered literacy orientation. The PPVT-III scores directly correlated with the number of AG visits with book given x number of books purchased (r2 = 0.025, p = 0.0006). Higher scores in EOWPVT-R were predicted by race and the number of visits with books given x number of books purchased (r2 = 0.182, p = 0.0009). All families reported reading together, half reporting positive familycentered literacy. Given the same number of books purchased for each child, the outcome scores were higher the greater the number of clinic visits wherein AG included early literacy and provision of books.

Diagnosis and Treatment Frequency for Overweight Children and Adolescents at Well Child Visits

Obesity in children is a rapidly growing problem and may be underrecognized by pediatricians. We reviewed 473 consecutive well child visits to assess frequency of correctly identifying overweight children. Of children with a body mass index greater than the 95th percentile for gender and age, only 27 (29%) were diagnosed as overweight by the physician. Our results suggest that the frequency of diagnosing children as overweight at well child visits is critically low.

147 FOLLOW-UP OF OVERWEIGHT CHILDREN AND ADOLESCENTS DIAGNOSED AT WELL-CHILD VISITS.

Background The prevalence of overweight children in the United States is increasing. Barriers to obesity diagnosis and treatment are multifactorial. As with other chronic conditions, timely follow-up is an essential component of treatment. The purpose of this study was to determine the compliance with follow-up of children diagnosed as overweight. Hypothesis Appropriate diagnosis and counseling of overweight children will lead to better compliance with follow-up. Methods A chart review was conducted on 2- to 17-year-old children who presented for well-child visits between 7/31 and 8/16/03 at an inner-city university-affiliated clinic. Diagnosis of overweight, BMI, comorbid conditions, demographic data, and follow-up appointment were recorded. A year later, a second chart review was done on those identified as overweight and their BMI, diagnosis, management, and compliance with follow-up were recorded. Results We reviewed 278 charts: 88% were African American, 56% male, and 94% on Medicaid. Fifty-eight children (21%) were overweight, but only 40 were correctly identified, including 16 with comorbid conditions, while 18 overweight were not diagnosed. Of the 40 children correctly diagnosed, 93% received dietary counseling, 85% exercise advice, and 60% were told to decrease their sedentary activities. Referral to a nutritionist was made for 16 children but only two kept their appointments. Follow-up appointments were made for 31 of 40 (78%) overweight: 18 in 4 weeks, 13 in 6 to 12 weeks. Only 3 children returned at the appointed time, but none mentioned overweight as a reason for the visit among the complaints presented. The physician also failed to discuss the overweight diagnosis of the previous visit. Conclusion Majority of children diagnosed as overweight received appropriate counseling and follow-up appointment. The majority (93%) failed to return, and those who returned did so for reasons other than the weight issue. The physician likewise failed to address the problem. Barriers to compliance by both patient and physician need to be explored if we are to solve the problem of obesity.

256 PEDIATRIC HYPERTENSION: TOO COMPLICATED TO RECOGNIZE

Purpose To determine whether pediatric providers recognize elevated blood pressures. The hypothesis is that fewer than 50% of elevated blood pressure values in children are recognized. Methods Children aged 3 to 17 years presenting for well visits at two university-based pediatric clinics, from July 31 to August 15, 2003, were included. Height, weight, and systolic blood pressures (SBP) and diastolic (DBP) were obtained. Height and body mass index (BMI) percentiles were determined. Using current table-based standards, SBP and DBP values were categorized as normal (< 90th %), borderline (90% to 94%), or hypertensive (95% or higher). Statistical analysis was done using chi-square test for dichotomous and the Student t-test for continuous variables with p values ≤ .05 considered significant. Results Of the 287 children, 161 (56.1%) had normal BP; 35 (12.2%) were borderline; and 90 (31.4%) were in the hypertensive range. The mean BMI was significantly higher (79%) for children in the hypertensive than in the normotensive (60%) range (p < .001). Only 13 (14.6%) with hypertensive BP were identified as elevated, which is significantly less than 50% recognition (p < .001). The mean BMI percentile was 92 for those recognized compared to 76 for those with unrecognized BP elevations (p = .001). Conclusions While it is likely that most elevated blood pressures obtained in the pediatric office do not represent hypertension, the diagnosis of hypertension is dependent upon the recognition of abnormal values. Given the current complexity for determining hypertension, it is not surprising that only 11% of elevated BP were recognized in this study. Hypertensive values in normal-weight children were recognized significantly less often than in the children with higher BMI percentiles. Future efforts should be directed towards developing a simpler definition of pediatric hypertension, one that is preferably based on the pathophysiological consequences than on statistical patterns.

24 CHILD LIFESTYLE CHOICES AND OBESITY

Background Obesity is the most common nutritional problem in our country. Objective To determine the prevalence of obesity among low-income inner-city children ages 2 to 17 years and to identify the association between obesity and the consumption of high calorie drinks (soda, juice, Kool-Aid, sweet tea), television viewing, and exercise. Methods A prospective sample of mothers of children ages 2-17 years who presented at two inner-city university affiliated pediatric clinics were surveyed and anthropomorphic, demographic, and lifestyle variables obtained. Using a 6 ounce cup as a visual cue, mothers were asked how many servings of juice, Kool-Aid, sweet tea, soda, water, and milk their children consumed on a daily basis. Mothers were also asked to estimate the amount of exercise and television viewing their children received. The height and weight of each child were measured and BMI calculated. Results The mothers of 504 children were surveyed (79.8% African-American, 91.9% Medicaid, 52.8% male). 112 (22.4%) children were overweight and 88 (17.5%) were at risk for being overweight. Older children (> 8 years) were more likely to watch > 2 hours of television per day (OR + 3.1 [2.1-4.6], p < .001) compared to younger children and were more likely to have a television in their bedroom (OR = 2.5 [1.6-3.9], p < .01). Mothers of older children were less likely to report one hour exercise per day (OR = 0.60 [0.40-0.87] p < .01). Overweight children were more likely to drink more than one 12 oz soda per day (OR = 2.4; 95% CI 1.4-4.2, p = .002) compared to thin children and this remained significant after controlling for age (p = .01). Juice consumption did not vary significantly between overweight and thin children. Conclusion Children older than eight years are more likely to have a television in their bedroom and watch > 2 hours of TV per day. In addition, they appear to have decreased physical activity compared to younger children. These factors, along with increased consumption of sugar containing beverages, may be contributing factors to the rise in pediatric obesity.

251 MATERNAL PERCEPTION OF THEIR CHILD'S WEIGHT IS A BARRIER TO EARLY DIAGNOSIS AND TREATMENT

Background Obesity has reached epidemic proportions in the United States. Previous research has shown that mothers of overweight children have difficulty identifying their children as overweight. Objective To determine and evaluate the associations of the actual and maternal perception of the childs weight. Methods A prospective sample of mothers of children aged 2-17 years who presented at two inner-city, university affiliated pediatric clinics were surveyed on whether they thought their childs weight was “just right,” “too light,” or “too heavy.” Mothers were asked to provide their own height and weight as well as that of the childs father if known. Other demographic variables were also collected. The height and weight of each child were measured and the BMI calculated for all three family members. Categories for adult BMI were as follows: < 25 = normal, 25-29.9 = overweight, ≥ 30 = obese. For pediatric BMI, less than 5% = underweight, 85-95% = at risk for overweight, > 95% = overweight. Results The mothers of 504 children were surveyed (79.8% African-American, 91.9% Medicaid, 52.8% male). For mothers, 157 (31%) were overweight and 215 (42.7%) were obese. For fathers, 174 (34.5%) were overweight, 161 (32%) were obese; data for 27 (5%) were not available. For children, 88 (17.5%) were at risk for being overweight, and 113 (22.4%) were overweight. If either mother (OR = 2.1; 95% CI 1.4-3.2, p < .001) or father (OR = 2.5; 95% CI 1.6-3.8, p < .001) was obese, their child was also more likely to be overweight. There was no difference in the accuracy of maternal perception when comparing overweight with nonoverweight children. However, when comparing overweight boys to girls, the boys were less likely to be accurately perceived by their mothers as too heavy (OR = 0.28; 95% CI 0.12-0.67, p = .003). Also, children less than eight years were less likely to be accurately perceived by their mothers (OR = .0451; 95% CI 0.31-0.656, p < .01) as overweight. Conclusions Obesity is a family problem, which may be complicated by inaccurate maternal perceptions. Young and male children are particularly susceptible to inaccurate perceptions. Families should be educated early on the risks and weight status of their children.