Robert M. Siegel

Screening for domestic violence in the community pediatric setting

Objective. Children exposed to domestic violence (DV) can experience a variety of adverse effects such as behavior disorders, developmental delay, and child abuse. Recently, the American Academy of Pediatrics recommended that all pediatricians incorporate screening for DV as a part of anticipatory guidance. To date, however, there is little information on how likely women are to disclose DV or whether there are any benefits to screening in the pediatric office setting. The purpose of our pilot study was to gain an understanding of whether screening for DV in the pediatric office setting could be helpful to abused women and their children. Methods. During a 3-month period, 92% of the women who accompanied their children for a well-child visit to a hospital-based suburban pediatrician were asked about violence in the home with a six-question screening tool. Results. Of the 154 women screened, 47 (31%) revealed DV at some time in their lives. Twenty-five women (17%) reported DV within the past 2 years and were reported to the mandated state agency. There were 5 episodes of child abuse reported of which two had not been previously reported. Interestingly, there were 5 women injured during their most recent pregnancy and who had separated from their abusive partner, but no legal action had been taken to protect them from their partners return. There was no significant difference in the incidence of DV reported in families with Medicaid (37%) versus private insurance (20%). Before routine DV screening in our office, only one previous DV report had been made in 4 years. Conclusions. Our preliminary results suggest that many women will reveal DV when screened in the pediatric office setting. Also, there is a subgroup of women, those with young children who have recently separated from their partners, who may particularly benefit from DV screening.

At What Age Can Children Report Dependably on Their Asthma Health Status

OBJECTIVE. This study examined psychometric properties and feasibility issues surrounding child-reported asthma health status data. METHODS. In separate interviews, parents and children completed 3 visits. Child questionnaires were interviewer administered. The primary instrument was the Childrens Health Survey for Asthma–Child Version, used to compute 3 scales (physical health, activities, and emotional health). The following were assessed: reliability (internal consistency and test-retest reliability), validity (general health status, symptom burden, and lung function), and feasibility (completion time, missing data, and inconsistent responses). RESULTS. A total of 414 parent-child pairs completed the study (mean child age: 11.5 years). Reliability estimates for the activities and emotional health scales were >.70 in all but 1 age category; 5 of 9 age groups had acceptable internal consistency ratings (≥.70) for the physical health scale. Cronbachs α tended to increase with child age. In general, test-retest correlations between forms and intraclass correlation coefficients were strong for all ages but tended to increase with child age. Correlations between forms ranged from .57 (7-year-old subjects, physical health) to .96 (14-year-old subjects, activities). Intraclass correlation coefficients ranged from .76 (13-year-old subjects, emotional health) to .94 (15–16-year-old subjects, physical health). Children with less symptom burden reported higher mean Childrens Health Survey for Asthma–Child Version scores (indicating better health status) for each scale, at significant levels for nearly all age groups. Childrens Health Survey for Asthma–Child Version completion times decreased from 12.9 minutes at age 7 to 6.9 minutes at age 13. CONCLUSIONS. This research indicates that children with asthma as young as 7 may be dependable and valuable reporters of their health. Data quality tends to improve with age.

A comparison of domestic violence screening methods in a pediatric office

In 1998, the American Academy of Pediatrics, recognizing the extreme impact of domestic violence (DV) on children, recommended that all pediatric providers screen for this problem.1 While one third of women will disclose DV when screened in the pediatric setting, practitioners have described several barriers to screening such as lack of time and discomfort addressing the problem.2,3 Screening in states that have Mandated Reporting Laws (MR) is further complicated with concerns of violating the practitioner-patient relationship and whether women are less likely to disclose in such a situation.4 Written, self-administered screens may be time-saving and have been shown to be effective in non-pediatric settings.4,5 MR, however, may present another barrier to screening and there is no information how MR or written questionnaires affect screening in the pediatric office setting. In our study, we compare the prevalence of DV reported by women using oral screening with and without disclosure of MR and a written self-administered screen in a pediatric office.

A 6-Month, Office-Based, Low-Carbohydrate Diet Intervention in Obese Teens:

Background. Previous studies have shown the success of a low-carbohydrate diet (LCD) in adults. In one study, the LCD has also been shown as safe and effective in teens, the study period was only 12 weeks. Furthermore, there is no information on whether the LCD is a practical intervention in a pediatric office setting. Objective. The object of this study was to demonstrate the effectiveness of a LCD in obese children in a primary care pediatric setting. Design/Methods . The study was done in 11 community pediatric practices. Children ages 12 to 18 years with a body mass index (BMI) greater than 95th percentile were put on a LCD of less than 50 grams of carbohydrate daily. Results . A total of 38 of the 63 teens finished the 6-month study and 32 (84%) lost weight (range from a gain of 5.5 kg to a loss of 23.9 kg). There was also a significant decrease in mean BMI (34.9 to 32.5). Conclusions. The LCD appears to an effective and practical office-based intervention in obese teenagers.

Perceived Utility of Parent-Generated Family Health History as a Health Promotion Tool in Pediatric Practice

Objectives. The purpose of this study was to describe how pediatric providers collect and use family health history (FHH) and their perceptions about My Family Health Portrait (MFHP) as a pediatric health promotion and disease prevention tool. Study design.A random sample of 148 pediatric providers was invited to participate in a semistructured qualitative interview. Transcripts were reviewed by 2 coders, and interrater reliability was determined. Results. In all, 21 providers were interviewed. All participants collected FHH at new visits and when patients presented with a symptom or complaint. Most providers believed that collecting FHH of chronic disease benefits the pediatric population. Time was the most commonly cited barrier to FHH collection; collecting FHH prior to the office visit was the most frequently cited facilitator. Providers believed that the use of MFHP would improve FHH collection and allow targeted education and preventive recommendations. Respondents also identified logistical and other issues that must be resolved to integrate MFHP into clinical practice. Conclusion. This research suggests that pediatric primary care presents many opportunities to collect and discuss FHH and that providers are optimistic about the clinical use of a parent-generated FHH collection tool. Future research should assess parent perspectives about the use of MFHP.

A Safety-Net Antibiotic Prescription for Otitis Media: The Effects of a PBRN Study on Patients and Practitioners

Pediatricians can decrease antibiotic use by treating acute otitis media (AOM) with a safety-net antibiotic prescription (SNAP). This study assessed whether the practitioners of the Practice-Based Research Network who participated in the study continued to use the SNAP and report a 60-day follow-up of the study patients. Charts were reviewed of study patients for 60 days following study enrollment. A survey on antibiotic use for AOM was mailed to the 17 study practitioners (SP) and 30 randomly selected community pediatricians (CP). Eight of the SP used the SNAP more than 20 times over the year following the study vs 1 of the CP. Sixty-two percent of patients never received antibiotics. The recurrence/relapse rate was greater in children younger than 2 years old compared to those older, 34% vs 10%. Practitioners who participate in a Practice-Based Research Network study are more likely to use a study intervention than others.

Mothers’ Perceptions of Family Health History and an Online, Parent-Generated Family Health History Tool:

Family health history (FHH) can identify families at increased risk for disease. Purpose. To learn mothers’ (1) perceptions of the benefits of FHH and (2) willingness to complete a FHH tool, My Family Health Portrait (MFHP). Methods. Qualitative in-depth interviews were conducted with mothers recruited through Cincinnati Children’s Hospital. Deductive and inductive codes were developed. Results. A total of 25 mothers were interviewed. Perceived benefits included keeping the pediatrician informed (n = 12; 48%) and preventive screenings recommended based on FHH (n = 10; 40%). Participants had positive impressions of MFHP and felt that it was user-friendly (n = 17; 68%). Lack of FHH knowledge was the most common challenge to completing MFHP, but most respondents stated that they would be able to complete MFHP prior to their child’s medical appointment (n = 23; 92%). Conclusion. Mothers are interested in and may be motivated to complete a parent-generated FHH prior to a pediatric appointment. Future research should focus on FHH implementation in practice.

Physician Knowledge and Management of Children Exposed to Domestic Violence in Ohio: A Comparison of Pediatricians and Family Physicians

Active members of the Ohio chapters of American Academy of Family Physicians (FP=1,498) and American Academy of Pediatrics (Ped=1,725) were surveyed about their knowledge and management regarding children exposed to domestic violence (DV). Characteristics of respondents were analyzed by use of Chi-square analysis. Logistic regression was performed to identify predictors of DV knowledge and management. The response rate was 33.3%. Family physicians were more likely to know their local DV agency and recognize the adult symptoms of DV, such as unexplained injury. Pediatricians were more likely to report the child who saw a fight between parents to child protective services. Continuing work to increase physicians’ comfort and ability to assess for DV and manage exposed children is needed.

The Feasibility of High-Intensity Interval Exercise in Obese Adolescents

Exercise is a critical component in the management of pediatric obesity. Currently, continuous aerobic exercise (AE) is the standard of care for pediatric weight management programs. The 2008 Physical Activity Guidelines for Americans primarily promote aerobic activity for children, and aerobic-based exercise at a steady intensity (AE) is typically prescribed in pediatric weight management programs1. Several studies in adults, however, show advantages of high-intensity interval exercise (HIIE) over continuous A Eat improving fitness and health in both healthy and obese people2–4. These benefits of HIIE compared to AE have also been demonstrated in some limited studies in children. In a sample of healthy prepubescent children, Borel et al showed the immediate effects on oxygen uptake (VO2) of HIIE to be comparable to continuous AE by continuously monitoring gas exchange of subjects at various points in an exercise protocol Farpour et al showed improved health and fitness measures in healthy children as a result of HIIE5,6. Some of this work in children extends into the obese population. Ingul et al showed that impaired cardiac function in obese adolescents can be improved by 3 months of HIIE training on a treadmill twice a week for 13 weeks7. Tjonna et al studied obese adolescents in twice weekly HIIE intervention for 12 weeks compared to subjects receiving bimonthly education from multidisciplinary health professionals8. HIIE was superior to educational classes at improving subject BMI, body fat, blood pressure, blood glucose, and endothelial function. A study from the Sao Paulo School of Medicine compared HIIE and AE in obese 8–12 year old children with treadmill training protocols twice a week for 12 weeks. Both were found to be equally effective in improving aerobic fitness, insulin sensitivity, and BMI in obese children but the study may have had too few enrolled to show a difference between modes of exercise9. While these few studies of HIIE in obese children have shown benefits on fitness and cardiovascular risk factors, the acceptability and enjoyment of this protocol in children is not clear. Enjoyment of the exercise is a crucial component if our goal is long-term adherence. Another limitation of many HIIE studies in children is restriction of the interval training to treadmill protocols; a more varied exercise protocol would be more comparable to the current standard of care, which includes group games and more variable equipment choices. The purpose of this HIIE study was to measure the enjoyment and acceptability of HIIE as well as the feasibility of a multimodal protocol in obese teenagers enrolled in a multi-disciplinary pediatric weight management program as a precursor for a larger, definitive study.

A Comparison of Low Glycemic Index and Staged Portion-Controlled Diets in Improving BMI of Obese Children in a Pediatric Weight Management Program:

Pediatric obesity is a major health issue with 12% of children ages 2 to 19 having a body mass index (BMI) greater than the 95th percentile for their age. Traditionally, a low-calorie, low-fat diet is recommended for obesity treatment in both adults and children. Although studies in children less 13 years show a modest benefit in lowering BMI in the short -term, long-term adherence of low-calorie diets is problematic. The glycemic index (GI) is a measure that characterizes the rate of carbohydrate absorption of a food. Foods with a low GI trigger a low insulin response and ultimately lead to satiety. Several studies show decreased appetite and weight loss with a low glycemic index diet (LGD) in adults. Pediatric studies are more limited, but also demonstrate shortterm BMI improvement with the LGD. Young et al combined both the “Traffic Light” approach with an LGD in children aged 5 to 12 years. In this 12-week intervention, 15 of 35 children had a significant decrease in BMI z score. In our study, we describe our experience using a heart-healthy LGD in a hospital-based pediatric weight management program.