National trends in the management of cardiovascular disease risk factors in children: second NHLBI survey of primary care physicians

Lifestyle and awareness of cholesterol blood levels among 29159 community school children in Italy

BACKGROUND AND AIM

Lifestyle habits including indoor and outdoor activities among community school children, adherence to the Mediterranean diet and awareness about total cholesterol blood levels represent determinant factors in cardiovascular disease (CVD) prevention. The aim of this study was to analyze the relationship between adherence to the Mediterranean diet, total cholesterol blood levels, body composition and hours per day spent in in-house or outdoor among 29,159 Italian 6-14 years-old community school children (50% boys). The KidMed questionnaire, modified to handle missing information on olive oil consumption, was used to assess the adherence to the Mediterranean diet among participants.

METHODS AND RESULTS

Associations between variables were tested according to 3 classes of the Mediterranean diet adherence score using analysis of variance. Participants with high adherence to Mediterranean diet were few (1%). Overall awareness of total cholesterol blood levels was low among children (4.5%), slightly higher among parents (26.2 and 24.1% in mothers and fathers, respectively). Among Mediterranean diet adherent children, BMI was significantly (p < 0.001) smaller than among the non-Mediterranean or intermediate adherent children as were the total hours spent per day watching television or playing with videogames (p < 0.001) whereas the hours/day in sport or outdoor activities were more (p < 0.001). These results were confirmed by multiple linear regression with KidMed scored 0 to 8 as dependent variable.

CONCLUSION

Although awareness of total cholesterol blood levels and adherence to the Mediterranean diet are rare among community school children, only among these a healthier lifestyle was practiced with a tendency to lower CVD risks. These results are important as the first sized experience of this type in Italy.

Temporal trends in lipid testing among children and adolescents: A population based study

Unfavorable lipid levels during childhood are associated with subsequent development of atherosclerotic cardiovascular disease. The American Academy of Pediatrics and National Heart, Lung and Blood Institute in 2011 recommended universal lipid screening for children between ages 9–11 years and between ages 17–21 years. The objective of the study was to determine temporal trends in lipid testing among children and young adults in a mid-western population. The Rochester Epidemiology Project database was used to identify lipid testing in ages 2–21 years (n = 51,176) in the Olmsted County population from January 1, 2008 through December 31, 2014. Generalized estimating equations with Poisson distribution were used to test for temporal trends in lipid testing across the age groups. There was modest increase in lipid testing in children in the age groups, 9–11 years and 17–21 years (1.5% in 2008 to 2.2% in 2014, P < 0.001 and 4.4% in 2008 to 4.6% in 2014, P = 0.02, respectively). There was a significant decrease in proportion of 17–21 year olds with elevated total cholesterol (16.2% in 2008 to 11.6% in 2014; P = 0.01) and non-high density lipoprotein cholesterol (22.6% in 2008 to 12.6% in 2014; P < 0.001). In this population-based study, rates of lipid testing increased minimally only in the last six years. Further longitudinal studies are warranted to improve guideline dissemination and address attitudes, practices and barriers to lipid testing in children and young adults.

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In 2011, universal lipid screening was recommended for children and young adults.

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We investigated temporal trends in lipid testing in a mid-western community.

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There was only a minimal increase in rates of lipid testing.

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There is need for improve guideline dissemination and implementation.

Cholesterol Screening and Treatment Practices and Preferences: A Survey of United States Pediatricians

OBJECTIVES

To determine pediatricians' practices, attitudes, and barriers regarding screening for and treatment of pediatric dyslipidemias in 9- to 11-year-olds and 17- to 21-year-olds.

STUDY DESIGN

American Academy of Pediatrics (AAP) 2013-2014 Periodic Survey of a national, randomly selected sample of 1627 practicing AAP physicians. Pediatricians' responses were described and modeled.

RESULTS

Of 614 (38%) respondents who met eligibility criteria, less than half (46%) were moderately/very knowledgeable about the 2008 AAP cholesterol statement; fewer were well-informed about 2011 National Heart, Lung, and Blood Institute Guidelines or 2007 US Preventive Service Task Force review (both 26%). Despite published recommendations, universal screening was not routine: 68% reported they never/rarely/sometimes screened healthy 9- to 11-year-olds. In contrast, more providers usually/most/all of the time screened based on family cardiovascular history (61%) and obesity (82%). Screening 17- to 21-year-olds was more common in all categories (P?<?.001). Only 58% agreed with universal screening, and 23% felt screening was low priority. Pediatricians uniformly provided lifestyle counseling but access to healthy food (81%), exercise (83%), and adherence to lifestyle recommendations (96%) were reported barriers. One-half of pediatricians (55%) reported a lack of local subspecialists. Although 62% and 89% believed statins were appropriate for children and adolescents with high low-density lipoprotein cholesterol (200?mg/dL) unresponsive to lifestyle, a minority initiated statins (8%, 21%).

CONCLUSIONS

US pediatricians report lipid screening and treatment practices that are largely at odds with existing recommendations, likely because of lack of knowledge and conflicts among national guidelines, and concern about treatment efficacy and harms. Education regarding pediatric lipid disorders could promote guideline implementation.

Managing Febrile Infants

The authors hypothesized that sepsis workup recommendations are associated with practice recommendations published during the physician’s residency. The first published recommendations suggesting sepsis workups for nontoxic, young, febrile infants appeared in pediatric journals from 1975-1980 and in family practice journals from 1981-1987. Data are from the Community Tracking Study (3,272 pediatricians and 2,432 family physicians). “Percentage of sepsis workups recommended” was defined by response to a vignette about the percentage of well-appearing 6-week-old children with a fever of 101°F for whom the physician would recommend a sepsis workup. Multivariable regression with piecewise linear functions evaluated workup recommendations by timing of literature recommendations during residency. Pediatricians recommended sepsis workups 81.6% of the time and family physicians 67.7% (p < .001). Increased recommendations occurred among pediatricians who completed residency from 1975-1980 (p < .05) and among family physicians who completed residency from 1981-1987 (p < .005), when specialty-specific journals published recommendations for sepsis workups for febrile infants. The association between publication of sepsis workup recommendations during a physician’s residency and increased sepsis workup recommendations suggests an unrecognized and enduring impact of such publications.

Temporal trends in lipid screening and therapy among youth from 2002 to 2012

BACKGROUND

Pediatric lipid management recommendations have evolved from selective screening to universal screening to identify and target therapy for genetic dyslipidemias. Data on the success of the selective screening guidelines for lipid testing, dyslipidemia detection, and lipid management are conflicting.

OBJECTIVE

To determine temporal trends in lipid testing, dyslipidemia categories and pharmacotherapy in a cohort of 653,642 individual youth aged 2 to 20 years from 2002 to 2012.

METHODS

Summary data on lipid test results, lipid-lowering medicine (LLM) dispensings, and International Classification of Diseases, Ninth Revision diagnoses were compiled from the virtual data warehouses of 5 sites in the Cardiovascular Research Network. Temporal trends were determined using linear regression.

RESULTS

Among the average 255,160 ± 25,506 children enrolled each year, lipid testing declined from 16% in 2002 to 11% in 2012 (P < .001 for trend). Among the entire population, the proportion newly detected each year with low-density lipoprotein cholesterol >190 mg/dL, a value commonly used to define familial hypercholesterolemia, increased over time from 0.03% to 0.06% (P = .03 for trend). There was no significant change over time in the proportion of the yearly population initiated on LLM or statins specifically (0.045 ± 0.009%, P = .59 [LLM] and 0.028 ± 0.006%, P = .25 [statin]).

CONCLUSIONS

Although lipid testing declined during 2002 to 2012, the detection of familial hypercholesterolemia-level low-density lipoprotein cholesterol increased. Despite this increased detection, pharmacotherapy did not increase over time. These findings highlight the need to enhance lipid screening and management strategies in high-risk youth.

Implementation of lipid screening guidelines in children by primary pediatric providers

OBJECTIVE

To assess the awareness and implementation of lipid guidelines among primary pediatric providers.

STUDY DESIGN

An online survey was administered to primary pediatric providers (n = 1488): pediatricians, family medicine/general practitioners, and advanced practitioners (nurse practitioners/physician assistants) in Minnesota. The survey was conducted over 12 weeks in 2012-2013. A multiple-choice questionnaire was used to evaluate the participants' knowledge, screening, and management attitudes regarding pediatric lipid guidelines.

RESULTS

The overall response rate was 39% (n = 548 of 1402 successful e-mails). Respondents were primarily pediatricians and family medicine practitioners (37% each), followed by general practitioners (11%) and advanced practitioners (nurse practitioners, 5.5%; physician assistants, 1.6%). Although 74% of providers reportedly believed that lipid screening and treatment would reduce future cardiovascular risk, 34% performed no screening, 50% screened selectively, and only 16% performed universal screening. Pediatricians were more likely to screen, with 30% performing universal screening and 41% performing selective screening. Among perceived barriers to screening, providers reported uneasiness addressing lipid disorders (43%), and unfamiliarity with screening guidelines (31%). The majority (83%) were uncomfortable managing lipid disorders, and 57% were opposed to the use of lipid-lowering medications in children.

CONCLUSION

These findings underscore the need to further educate providers and supply easily accessible information on the screening and treatment of childhood lipid disorders.

Why pediatricians fail to diagnose hypertension: a multicenter survey

OBJECTIVE

To elucidate why pediatricians fail to diagnose childhood hypertension, with special emphasis on the use of blood pressure (BP) reference data. We hypothesized that pediatricians frequently omit BP measurements and do not routinely relate BP measurements to reference data.

STUDY DESIGN

We conducted a multicenter survey on BP measurement among 197 participants. Respondents were asked to estimate BP percentiles and classify BP readings in 12 example cases. Questionnaires were completed onsite in the presence of the researchers, without access to BP reference data.

RESULTS

We found that 71% of physicians measure BP during ambulatory visits only if the child has risk factors for hypertension. After measuring BP, 65% compare the reading with reference data only if they suspect that it is elevated. Their ability to rate a reading at its true value is limited, however; 47% of the physicians classified 1 or more of the prehypertensive or hypertensive cases as normal.

CONCLUSIONS

Most pediatricians do not screen for hypertension, contrary to recommendations. After obtaining a BP measurement, the majority do not compare the reading with reference standards; however, without the use of reference data, they commonly underestimate the BP percentile and potentially miss cases of childhood hypertension.

Systolic peak detection in acceleration photoplethysmograms measured from emergency responders in tropical conditions

Photoplethysmogram (PPG) monitoring is not only essential for critically ill patients in hospitals or at home, but also for those undergoing exercise testing. However, processing PPG signals measured after exercise is challenging, especially if the environment is hot and humid. In this paper, we propose a novel algorithm that can detect systolic peaks under challenging conditions, as in the case of emergency responders in tropical conditions. Accurate systolic-peak detection is an important first step for the analysis of heart rate variability. Algorithms based on local maxima-minima, first-derivative, and slope sum are evaluated, and a new algorithm is introduced to improve the detection rate. With 40 healthy subjects, the new algorithm demonstrates the highest overall detection accuracy (99.84% sensitivity, 99.89% positive predictivity). Existing algorithms, such as Billauer's, Li's and Zong's, have comparable although lower accuracy. However, the proposed algorithm presents an advantage for real-time applications by avoiding human intervention in threshold determination. For best performance, we show that a combination of two event-related moving averages with an offset threshold has an advantage in detecting systolic peaks, even in heat-stressed PPG signals.

Exclusive breastfeeding and other foods in the first six months of life: effects on nutritional status and body composition of Brazilian children

OBJECTIVE

To evaluate the effect of exclusive breastfeeding and consumption of other foods in the first six months of life in the nutritional status and body composition of children.

METHODS

A retrospective cohort study with 185 children aged from 4 to 7 years was monitored during the first months of life in a program of support to breastfeeding. We evaluated weight, height, waist circumference, and body composition by using DEXA. The nutritional status was assessed by the BMI/age index. The parameters of adiposity were classified by using as the cutoff point, the 85th percentile of the sample itself, according to gender and age. Confounding factors considered were variables related to maternal, pregnancy, birth, sociodemographic, health, lifestyle, and diet. Bivariate and multivariate analyses were performed, the latter by means of multiple logistic regression.

RESULTS

The median exclusive breastfeeding was 3 months. Of the children, 42.7% received cow's milk and 35.7% received infant formula. Regarding nutritional status, 21.1% of the children showed changes. The variables of infant feeding were not independently associated with nutritional status and body composition of the children and there were no differences between the groups studied.

CONCLUSION

Breastfeeding was not a protective factor to overweight and body fat in children.

Hypertension screening during ambulatory pediatric visits in the United States, 2000-2009

BACKGROUND AND OBJECTIVE

Hypertension occurs in 2% to 5% of children in the United States, and its prevalence has increased during the obesity epidemic. There is no consensus among professional organizations about how frequently blood pressure should be measured in children >3 years old. The purpose of this study was to estimate the frequency of hypertension screening during ambulatory pediatric visits in the United States and to determine patient- and provider-level factors associated with screening during visits specifically for preventive care.

METHODS

We analyzed data from a nationally representative sample of ambulatory visits by using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 2000 through 2009. In the subset of visits involving patients aged 3 to 18 years, we estimated the frequency of screening during all visits, preventive visits, and preventive visits in which overweight/obesity was diagnosed. We used multivariable logistic regression to identify patient- and provider-level factors associated with screening.

RESULTS

Hypertension screening occurred during 35% of ambulatory pediatric visits, 67% of preventive visits, and 84% of preventive visits in which overweight/obesity was diagnosed. Between 2000 and 2009, the frequency of screening increased in all visits and in preventive visits. Factors independently associated with screening included older age and overweight/obesity diagnosis.

CONCLUSIONS

Providers do not measure blood pressure in two-thirds of pediatric visits and one-third of pediatric preventive visits. Providers may understand the importance of screening among overweight/obese children; however, efforts to encourage routine screening, particularly in young children, may be needed.

Evaluation and treatment of hypertension in general pediatric practice

Hypertension (HTN) in children and adolescents has become increasingly common. We sought to identify variability in the approach to HTN among general pediatricians as well as obstacles to care of hypertensive youth by surveying pediatricians referring to an urban children's hospital. Although most pediatricians begin blood pressure measurement at 3 years, there was substantial variability in the initial diagnostic evaluation of hypertensive patients. Just 7% of pediatricians routinely start antihypertensive drug treatment for HTN, whereas 82% refer their hypertensive patients to a specialist; 40% of pediatricians felt uncomfortable evaluating and treating HTN. Pediatricians unfamiliar with The Fourth Report were more likely to be uncomfortable with the care of hypertensive patients than those familiar with it (54% vs 33%, P < .05). Current practice does not appear to follow recent consensus recommendations. Interventions designed to address the issues identified in this survey may lead to improved care for pediatric patients with HTN.

Health status and health care expenditures in a nationally representative sample: how do overweight and healthy-weight children compare?

OBJECTIVE

Childhood overweight is epidemic in the United States. Although limited, previous studies suggest that overweight children have chronic health problems. A more complete understanding of the effect of overweight on children's health requires a nationally representative, population-based sample. Our objective was to examine whether overweight children have (1) more chronic conditions, (2) poorer health, and (3) greater health care expenditures than healthy-weight children.

PATIENTS AND METHODS

This was a cross-sectional study of children aged 6 to 17 years participating in 1 of 2 nationally representative surveys of civilian, noninstitutionalized Americans, the 2001-2002 National Health and Nutrition Examination Survey and 2002 Medical Expenditure Panel Survey. The main outcome measures were prevalence of dyslipidemia, hyperglycemia, and hypertension; self-reported health status; and health care expenditures.

RESULTS

Overweight children, compared with healthy-weight children, have significantly increased risk for high total cholesterol levels (15.7% vs 7.2%), high low-density lipoprotein (11.4% vs 7.7%) or borderline low-density lipoprotein cholesterol levels (20.2% vs 12.5%), low high-density lipoprotein cholesterol levels (15.5% vs 3.0%), high triglyceride levels (6.7% vs 2.1%), high fasting glucose levels (2.9% vs 0.0%), high glycohemoglobin levels (3.7% vs 0.5%), and high systolic blood pressure (9.0% vs 1.6%). Overweight children, compared with healthy-weight children, demonstrate significantly lower prevalence of excellent health (National Health and Nutrition Examination Survey: 36.5% vs 53.3%; Medical Expenditure Panel Survey: 42.8% vs 55.6%). These differences persist in multiple regression models that control for potential confounders. In adjusted analyses, expenditures were comparable between overweight and healthy-weight children.

CONCLUSIONS

Our data demonstrate that overweight children have more chronic conditions and poorer health but have health care expenditures that are no greater than those for healthy-weight children. Addressing the health care needs of overweight children may prevent the development of chronic conditions and improve health status. These findings demonstrate the need to more thoroughly consider whether (1) overweight children have appropriate access to care, (2) physicians fully recognize the impact of overweight, and (3) physicians have resources to address overweight.

Sensitivity and specificity of pediatric lipid determinations for adult lipid status: findings from the Princeton Lipid Research Clinics Prevalence Program Follow-up Study

OBJECTIVE

The goal was to determine the diagnostic utility of the National Cholesterol Education Program pediatric guidelines.

METHODS

With the use of pediatric lipid data from the Cincinnati Clinic of the Lipid Research Clinics Prevalence Study and lipid and cardiovascular disease data collected for the same subjects as adults in the Princeton Follow-up Study, the sensitivity and specificity of the National Cholesterol Education Program pediatric guidelines were calculated overall and according to age. Furthermore, whether use of parental cardiovascular disease history during childhood influenced the sensitivity and specificity was assessed.

RESULTS

Overall sensitivities were 43% to 46% and specificities were 82% to 86% for total and low-density lipoprotein cholesterol levels. There was considerable variation in sensitivities according to age, with the lowest sensitivities at ages 14 to 16 years and the highest sensitivities at ages 5 to 10 years and 17 to 19 years. Results were similar whether or not the population was restricted to children with a positive parental history of cardiovascular disease.

CONCLUSIONS

Results of our analyses suggest that the sensitivity and specificity for evaluating total cholesterol or low-density lipoprotein cholesterol levels that are elevated in adulthood are not improved by selecting children with a positive parental history. These data also show the strong role that age (particularly the pubertal years between 10 and 15 years of age) plays in lipid measurements for children and adolescents. Continued prospective and longitudinal studies designed with age as well as other risk parameters are needed to determine the best guidelines for clinical screening in the future.

Preventive services: blood pressure checks at well child visits

The objective of this study was to determine rates of blood pressure (BP) screening at well-child visits as recommended by the Task Force on Blood Pressure Control in Children. The 1985 and 1996 National Ambulatory Medical Care Surveys were analyzed for changes in proportion of well visits for children aged 3-18 years at which BP was checked. Patient and physician demographics are described. BP screening increased from 50% in 1985 to 61% in 1996. For pediatricians, the estimates were 50% (95% CI, 43-57) and 60% (95% CI, 53-68). For family/general medicine the estimates were 51% (95% CI, 34-69) and 58% (95% CI, 43-74). Age, geographic location, and length of a visit were significant in predicting BP screening. Gender, race, ethnicity, or urban location were not. A stepwise logistic regression confirmed these results. Rates of screening BP at well-child visits have increased but fall short of current recommendations. High-risk children are not screened at a rate different from their lower risk peers.

A randomized crossover trial of combination pharmacologic therapy in children with familial hyperlipidemia

We sought to determine whether a low-dose combination of a bile acid-binding resin (colestipol) with an hydroxymethylglutaryl CoA reductase inhibitor (pravastatin) would result in improved acceptability, compliance, and effectiveness in lipid-lowering compared with conventional therapy with a higher dose of a bile acid-binding resin only, with fewer side effects. We performed a randomized, crossover open-label clinical trial with two 18-wk medication regimens separated by an 8-wk washout period in 36 children and adolescents with familial hypercholesterolemia or familial combined hyperlipidemia. The regimens included colestipol 10 g/d (10 pills) versus a combination of colestipol 5 g/d with pravastatin 10 mg/d (six pills). All patients were maintained on a fat-reduced diet. Acceptability was better with the combination regimen. Mean compliance was similar and suboptimal (approximately 60%) with all medication components. Mean relative LDL cholesterol lowering was significantly better with the combination regimen (-17 +/- 16% versus -10 +/- 13%; p = 0.045), although insufficient to achieve recommended target values in the majority of patients on either regimen. Both regimens were equally free of adverse effects, with no important effect on chemistry or hematologic values. Patient-reported adverse effects were more common with the conventional-dose colestipol-only regimen. Compliance with medication regimens using the bile acid-binding resins is suboptimal, although combination with a low dose of a statin may result in better lipid lowering.