Kenneth A. Lombard

Impact of a Primary Care Intervention on Physician Practice and Patient and Family Behavior: Keep ME Healthy—The Maine Youth Overweight Collaborative

OBJECTIVE. To evaluate the effect of a pediatric primary care–based intervention, on improved clinical decision support and family management of risk behaviors for childhood overweight. METHODS. An experimental field trial was conducted with 12 intervention sites in urban and rural areas of Maine and nonrandomized control sites. Change was assessed by using clinical and parent measures from 9 intervention and 10 control sites before and during the Maine Youth Overweight Collaborative intervention. Longitudinal information was collected from chart audits of patients aged 5–18 years (n = 600), systematic samples of parents collected before (n = 346) and during (n = 386) the intervention in 12 sites, and systematic samples of parents in 9 intervention (n = 235) and 10 control (n = 304) sites collected during the intervention. Surveys of health care providers (n = 14 and 17) before and during the intervention were also collected. Teams worked over 18 months to implement improvements in clinical decision support, including tracking BMI percentiles, identification of overweight patients, appropriate laboratory tests, counseling of families and patients use of a behavioral screening tool, and other improvements following the chronic-care model targeting patients aged 5 to 18 and their families. RESULTS. Large changes occurred in clinical practice from before to during the Maine Youth Overweight Collaborative: increases in assessment of BMI (38%–94%), BMI percentile for age and gender (25%–89%), use of the 5-2-1-0 behavioral screening tool (0%–82%), and weight classification (19%–75%). Parent surveys indicated improvements in providers’ behavior and rates of counseling. Intervention providers reported improvements in knowledge, attitudes, self-efficacy, and practice. CONCLUSIONS. The Maine Youth Overweight Collaborative intervention improved clinical decision support and family management of risk behaviors, indicating a promising primary care–based approach to address overweight risk among children and youth.

Erythrocyte incorporation and absorption of 58Fe in premature infants treated with erythropoietin

We hypothesized that treatment of very low birth weight premature infants with r-HuEPO would increase erythrocyte incorporation and gastrointestinal absorption of iron. Infants with birth weights ≤1.25 kg and gestational ages <31 wk were randomized to receive 6 wk of 500 U of r-HuEPO/kg/wk (epo group, n = 7) or placebo (placebo group, n = 7). All infants received daily enteral supplementation with 6 mg of elemental iron per kg. An enteral test dose of a stable iron isotope, 58Fe, was administered after the 1st (“early dosing”) and 4th (“late dosing”) wk of treatment. Mean (±SD) erythrocyte incorporation of the dose of 58Fe administered determined 2 wk after early dosing was significantly greater in the epo group compared with the placebo group (4.4%± 1.6 versus 2.0 ± 1.4%, p = 0.013). In contrast, after late 58Fe dosing, there was no difference between groups in incorporation (3.8 ± 1.6% versus 5.5 ± 2.7%). Within the epo group, percentage erythrocyte incorporation of58 Fe did not differ between early and late dosing, whereas in the placebo group it increased 3-fold (p < 0.01). Percentage absorption of 58Fe was not different between the epo and placebo groups after both early dosing (30 ± 22% versus 34 ± 8%) and late dosing (32 ± 9% versus 31 ± 6%). Absorption of nonlabeled elemental iron and 58Fe were significantly correlated with one another. The percentage of the absorbed 58Fe dose incorporated into Hb was not different between groups. We conclude that, although erythropoietin treatment stimulates erythrocyte iron incorporation in premature infants, it has no effect on iron absorption at the r-HuEPO dose studied.

Nutritional Management of Infants With Bronchopulmonary Dysplasia

The nutritional needs of the child with bronchopulmonary dysplasia (BPD) vary significantly from those of a healthy child. To address the many special aspects of the nutritional care of the child with BPD, a nutrition management protocol was established at the University of Iowa Hospitals and Clinics. This protocol discusses caloric requirements; selection of enteral feedings; electrolyte, vitamin, and mineral supplements; growth, oral feeding advancement, and monitoring of nutritional status. Although many of the guidelines are supported by research, some are based on clinical practice. Many questions remain to be answered about the optimal nutrition therapy for these infants. One goal of this protocol is to stimulate discussion and research that will lead to a better understanding of the nutritional requirements of the BPD population.

417 Iron Absorption and Red Blood Cell Incorporation Following Enteral and Intravenous Administration in Erythropoietin-Treated Premature Infants

417 Iron Absorption and Red Blood Cell Incorporation Following Enteral and Intravenous Administration in Erythropoietin-Treated Premature Infants

Effect of a Lactase Preparation on Lactose Content and Osmolality of Preterm and Term Infant Formulas

Lactose intolerance due to lactase deficiency often follows acute gastroenteritis. In such situations, a lactose-free formula may be indicated for preterm infants. Therefore, the effect of addition of lactase on the lactose content and osmolality of preterm and term infant formulas was studied. Lactose content of formulas at room temperature was decreased by approximately 50% 1 hour after addition of lactase. Concentration of lactose was reduced by 70% or more after 2 hours in all formulas. Because of the higher initial lactose concentration in term formulas, it took 24 hours to reach the same absolute lactose concentration (10 g/kg formula) found in preterm formulas after 2 hours. There was a moderate increase in osmolality in preterm formulas. The increase was greater in term formulas because of the greater initial concentration of lactose. The addition of lactase appears to be a suitable method for reduction of lactose content of preterm and term formulas, although the increase in osmolality of term formulas may preclude their clinical use.

Evaluation of a primary care intervention on body mass index: the Maine Youth Overweight Collaborative.

BACKGROUND We evaluated the impact of a brief primary-care-based intervention, The Maine Youth Overweight Collaborative (MYOC), on BMI (kg/m(2)) z-score change among participants with obesity (BMI ≥95th percentile for age and sex), overweight (BMI ≥85th and <95th percentile), and healthy weight (≥50th and <85th percentile). METHODS A quasi-experimental field trial with nine intervention and nine control sites in urban and rural areas of Maine, MYOC focused on improvements in clinical decision support, charting BMI percentile, identifying patients with obesity, appropriate lab tests, and counseling families/patients. Retrospective longitudinal record reviews assessed BMI z-scores preintervention (from 1999 through October 2004) and one postintervention time point (between December 2006 and March 2008). Participants were youth ages 5-18 having two visits before the intervention with weight percentile greater than or equal to 95% (N=265). Secondary analyses focused on youths who are overweight (N=215) and healthy weight youth (N=506). RESULTS Although the MYOC intervention demonstrated significant provider and office system improvements, we found no significant changes in BMI z-scores in intervention versus control youth pre- to postintervention and significant flattening of upward trends among both intervention and control sites (p<0.001). CONCLUSIONS This brief office-based intervention was associated with no significant improvement in BMI z-scores, compared to control sites. An important avenue for obesity prevention and treatment as part of a multisector approach in communities, this type of primary care intervention alone may be unlikely to impact BMI improvement given the limited dosage-an estimated 4-6 minutes for one patient contact.

Parenteral Iron Lacks Erythropoietic Efficacy in EPO-Treated Premature Infants |[dagger]| 953

The modest efficacy reported for r-HuEPO in decreasing RBC transfusion needs among premature infants has spawned efforts to devise strategies for increasing r-HuEPOs efficacy. Because iron (Fe) availability in plasma may limit EPOs efficacy, we hypothesized that when used as an adjunct to EPO treatment, parenteral Fe at doses equivalent to in utero accretion would increase erythropoiesis. Stable premature infants <31 wk gest age and<1.25 kg receiving enteral feeding were prospectively enrolled in an open, randomized, controlled trial. All three groups received oral Fe supplementation with 9 mg Fe-polymaltose complex/kg-d. Three study groups were compared: Group#1=Control; Group#2=600 U EPO/kg 3x/wk; and Group#3=2 mg parenteral Fe saccharate/kg-d plus EPO. No infant was transfused during the study. Mean (±SEM) demographic (Table) and laboratory data at the start of treatment (T=0) among the 3 groups were not different (not shown). At the end of 3 wks of treatment, Hb, reticulocyte count & transferrin receptor (TfR) levels were all higher (P<0.01) in the two EPO-treated groups (Table)--but with no added benefit from parenteral Fe. Parenteral Fe did not result in an increase in plasma Fe; instead plasma Fe was equivalently low in both EPO-treated groups(P<0.01). Plasma ferritin (ferr) was increased among infants receiving parenteral Fe treatment (P<0.01). We conclude that in stable preterm infants receiving enteral feeds and supplemental oral Fe, parenteral treatment with Fe does not augment erythropoietic stimulation beyond that of EPO alone. (Supported by MOD Grant #FY96-1055 & Vifor International, St. Gallen, Switzerland.)