Participation in a School-Based Wellness Initiative Associated With Improved K-12 Student Body Mass Index Trends

BACKGROUND

Associations between school participation in an academic medical center-supported school-based wellness initiative and programmatic components implemented with change in average student body mass index (BMI) over time were examined.

METHODS

This was an observational study of 103 K-12 South Carolina schools over school years 2014-2018, classified as participating (n = 87 schools, 27,855 students) or non-participating (n = 16 schools; 3608 students). Associations between students' BMI z-score (BMIz) and school participation were evaluated by linear multilevel mixed-effects modeling using data from FitnessGram and the School Wellness Checklist© (SWC), respectively.

RESULTS

One-third of the students had a BMI percentile ≥85. Average student BMIz decreased in participating schools (p = .026) and increased in non-participating schools (p = .004) over time. For schools that participated two or more years, there was an inverse relationship between SWC score and student BMIz (p = .002) that did not differ by school type, rural/urban location, Title 1 status, or student sex. Physical activity and stress management interventions for students, as well as employee wellness and establishing a wellness committee at the school level were significantly associated with decreased average student BMIz (all p < .05).

CONCLUSION

Implementation of similar comprehensive school-based wellness programs focused on improving physical activity, stress management, and employee engagement may help prevent and reduce pediatric obesity in diverse communities.

Investigation of a Common Clinical Approach to Poor Growth in Preterm Infants

OBJECTIVE

This study aimed to determine the effect of elevated energy intake with medium-chain triglyceride (MCT) oil or formula powder on growth velocity and weight z-score in very low birth weight infants receiving human milk and human milk fortifier.

STUDY DESIGN

This was a cohort study of infants exposed to MCT oil or formula powder for at least 7 days. Mean 7-day change in growth velocity and weight z-scores were compared pre- and postintervention.

RESULTS

Forty-three infants received increased energy with either MCT oil or formula powder. Infants receiving MCT oil were more preterm and had a lower birth weight. When evaluating 7-day changes pre- and postintervention, growth velocity increased from 10.0 g/kg/day to 19.8 g/kg/day, and change in weight Z-score increased from -0.24 to 0.05.

CONCLUSION

This clinical approach using MCT oil or formula powder for additional energy was associated with improved, at least short-term, growth velocity and weight z-score trajectory.

Early continuous renal replacement therapy during infant extracorporeal life support is associated with decreased lung opacification

Lung opacification on chest radiography (CXR) is common during extracorporeal life support (ECLS), often resulting from pulmonary edema or inflammation. Concurrent use of continuous renal replacement therapy (CRRT) during ECLS is associated with improved fluid balance and cytokine filtration; through modification of these pathologic states, CRRT may modulate lung opacification observed on CXRs. We hypothesize that early CRRT use during infant ECLS decreases lung opacification on CXR. We conducted a retrospective cohort study comparing CXRs from infants receiving ECLS and early CRRT (n = 7) to matched infants who received ECLS alone (n = 7). The CXR obtained prior to ECLS, all CXRs obtained within the first 72 h of ECLS, and daily CXRs for the remainder of the ECLS course were analyzed. The outcome measure was the degree of opacification, determined by independent assessment of two, blinded pediatric radiologists using a modified Edwards et al.'s lung opacification scoring system (from Score 0: no opacification to Score 5: complete opacification). 220 CXRs were assessed (cases: 93, controls: 127). Inter-rater reliability was established (Cohen's weighted к = 0.74; p < 0.0001, good agreement). At baseline, the mean opacification score difference between cases and controls was 1 point (cases: 1.8, controls 2.8; p = 0.049). Using mixed modeling analysis for repeated measures accounting for differences at baseline, the average overall opacification score was 1.2 points lower in cases than controls (cases: 2.1, controls: 3.3; p < 0.0001). The overall distribution of scores was lower in cases than controls. Early CRRT utilization during infant ECLS was associated with decreased lung opacification on CXR.

Primary Care Providers Welcome Smartphone Apps That Assist in Pediatric Weight Management

Primary care providers (PCPs) have few resources to manage their overweight/obese patients. The purpose of study was to determine if technological resources, such as smartphone apps, may be useful for weight management counseling. PCPs were surveyed about their current use of resources for obesity management and whether smartphone apps would be helpful. Seventy-four PCPs completed the survey. Only 15% currently referred patients to smartphone apps at least sometimes or more often. When asked about features of apps, 66% were not aware of apps with interactive healthy eating games, yet if aware, 45% reported they would refer patients. Providers reported a greater likelihood of being more effective using an app compared with their current ability to manage overweight/obesity, 3.19 versus 2.85, P < .01. The majority of pediatric providers surveyed do not provide technological resources for their overweight/obese patients; yet, they appear interested in using smartphone apps as a resource.

The Safety of Mother's Milk® Tea: Results of a Randomized Double-Blind, Controlled Study in Fully Breastfeeding Mothers and Their Infants

BACKGROUND

Various natural products are reported to improve maternal milk supply yet are not necessarily safe for infants. Researchers have not systematically studied galactagogue teas for safety.

RESEARCH AIM

This study evaluates the safety of a galactagogue tea in breastfeeding women and their infants, assessing short- and long-term adverse effects.

METHODS

Healthy, exclusively/fully breastfeeding women ( N = 60) with no milk insufficiency were randomized into (1) an all-natural tea containing fruits of bitter fennel, anise, and coriander; fenugreek seed; and other herbs (Mother's Milk^® herbal tea; test) group or (2) a lemon verbena leaf (placebo) group. Maternal diaries captured self-reported maternal and infant adverse effects, tea consumed, and perceived infant satisfaction. Maternal quality of life and psychological state were assessed at baseline and 2 and 4 weeks. Poststudy calls assessed adverse effects through the infants' age of 12 months.

RESULTS

No adverse effects attributable to the interventions were reported at any time point. No differences were found between test and placebo groups in sociodemographic characteristics, maternal or infant adverse symptoms, quality of life, breastfeeding self-efficacy, maternal psychological measures, infant growth, and infant satisfaction (all p >.05).

CONCLUSIONS

This double-blind, randomized controlled trial (RCT) of an herbal galactagogue versus placebo among healthy, exclusively/fully breastfeeding mothers and infants found no adverse events associated with the test tea across the 30-day study or the first year of their infant's life. This composite tea appears to present no safety risk for mothers or their young babies.

Biological correlates of self-reported new and continued abstinence in cannabis cessation treatment clinical trials

BACKGROUND

The agreement between self-reported cannabis abstinence with urine cannabinoid concentrations in a clinical trials setting is not well characterized. We assessed the agreement between various cannabinoid cutoffs and self-reported abstinence across three clinical trials, one including contingency management for abstinence.

METHODS

Three cannabis cessation clinical trials where participants reported use and provided weekly urine samples for cannabis and creatinine concentration measurements were included. Bootstrapped data were assessed for agreement between self-reported 7+ day abstinence and urine cannabinoid tests using generalized linear mixed effects models for clustered binary outcomes. One study implemented contingency management for cannabis abstinence. Four hundred and seventy-three participants with 3787 valid urine specimens were included. Urine was analyzed for 11-nor-9-carboxy-Δ9-tetrahydrocannabinol and creatinine using immunoassay methods Biological cutoffs of 50, 100, and 200 ng/ml, as well as changes in CN normalized THCCOOH (25%/50% decrease), were assessed for agreement with self-reported abstinence during the three clinical trials.

RESULTS

Agreement between measured THCCOOH and self-reported abstinence increases with increasing cutoff concentrations, while the agreement with self-reported non-abstinence decreases with increasing cutoff concentrations. Combining THCCOOH cutoffs with recent changes in CN-THCCOOH provides a better agreement in those self-reporting abstinence. Participants in the studies that received CM for abstinence had a lower agreement between self-reported abstinence and returned to use than those in studies that did not have a contingency management component.

CONCLUSION

Using combinations of biological measurements and self-reported abstinence, confirmation of study related abstinence may be verifiable earlier and with greater accuracy than relying on a single measurement.

Enhancing Postdischarge Asthma Care by Using Pharmacy Claims and Telephone Follow-up

BACKGROUND AND OBJECTIVES

Asthma is a common reason for hospital readmission. The majority of children are not receiving adequate preventive care after discharge. Our objective is to decrease return visits to the emergency department (ED) or hospital for asthma through a series of interventions (eg, access to real-time claims data and structured follow-up phone calls) designed to increase preventive care.

METHODS

We performed a single-site quality improvement project for children 2 to 17 years old discharged with asthma from January 2010 to March 2014. We compared a baseline period and a stepwise intervention period including the following: brief follow-up phone calls to families, access to medication claims data, and structured phone calls. The primary outcome of return visits to the ED or hospital and preventive care outcomes (controller refills and ambulatory visits) up to 90 days were assessed using state all-payer and Medicaid data sets. Interrupted time series analysis was used to investigate secular trends.

RESULTS

Six hundred and seventy-seven asthma discharges were analyzed. The majority of children were 2 to 7 years old, African American, and insured by Medicaid. Successful phone contact occurred in 57% of encounters. Ninety-day revisits to the ED or hospital demonstrated a significant decline (15% to 8%; P < .05), but preventive care measures did not improve.

CONCLUSIONS

A process to improve transitions for children who are hospitalized with an asthma exacerbation that includes follow-up phone calls was associated with a decrease in ED or hospital revisits. The lack of a detectable increase in preventive care warrants further exploration.

Newborn Screening for Sickle Cell Disease in St. Vincent and the Grenadines: Results of a Pilot Newborn Screening Program

Objective: To pilot a newborn screening program for sickle cell disease (SCD) in St. Vincent and the Grenadines using a novel partnership method to determine the feasibility of a universal newborn screening program in this country. Methods: A prospective study of mothers and their newborns was conducted between January 1, 2015, and November 1, 2015, at the country's main hospital. Mothers of infants born at this hospital were offered screening for SCD for their infants. If accepted, the newborn's heel-stick blood specimen was obtained and mailed to the South Carolina Department of Health and Environmental Control Newborn Screening Laboratory for testing. Samples were analyzed for variant hemoglobins using standard laboratory techniques and results were communicated to local physicians. Feasibility was determined by a benchmark of having >50% of SCD patients receive the diagnosis and initiate disease-specific care by 3 months of age. Descriptive statistics were completed using SAS 9.4. Results: There were 1147 newborn infants screened for SCD. Of these, 123 (10.7%) had results indicative of sickle trait and 3 patients (0.3%) were diagnosed with SCD: 1 with HbSS and 2 with HbSC. All 3 patients with SCD received treatment before 3 months of age. Conclusions: A newborn screening program is feasible in this population when partnered with an established newborn screening laboratory.

Underdiagnosis and Lower Rates of Office Visits for Overweight/Obese Pediatric Patients in Rural Compared with Urban Areas

OBJECTIVES

This study compared the number of children enrolled in Medicaid in rural and urban areas of South Carolina with an overweight/obesity diagnosis and the mean rates of office visits with overweight/obesity diagnosed.

METHODS

Medicaid claims data from 2012 for children in three South Carolina counties, categorized as urban, rural high resource, and rural low resource, were used to identify those who had been diagnosed as being overweight/obese during any encounter. Logistic and Poisson regressions were performed to predict whether overweight/obese children in each county would receive an overweight/obesity visit diagnosis and to calculate the mean rate of total office visits with an overweight/obesity diagnosis in each county.

RESULTS

A total of 1233 children enrolled in Medicaid were diagnosed as being overweight/obese at any encounter in the designated counties. Well visits with overweight/obesity diagnosed varied significantly, with 42.6%, 28%, and 11% in urban, rural high-resource counties, and rural low-resource counties, respectively (P < 0.01). In the logistic regression rural high-resource children (adjusted odds ratio 0.58, 95% confidence interval 0.38-0.88) and rural low-resource children (adjusted odds ratio 0.16, 95% confidence interval 0.09-0.28) were less likely than urban children to be diagnosed as being overweight/obese at a well visit. All of the children had a low number of total office visits with overweight/obesity diagnosed. When comparing the counties, urban children (1.22 visits per year) had more visits than rural low-resource children (0.75 visits per year, P < 0.01) and rural high-resource children (0.89 visits per year, P < 0.01).

CONCLUSIONS

Overweight/obesity is underdiagnosed in rural children enrolled in Medicaid in South Carolina, which affects the number of children who receive help to manage their weight. Interventions to overcome barriers of diagnosis and management are necessary to address childhood obesity properly.

Associations Between Patient Characteristics and the Amount of Arthritis Medication Information Patients Receive

Little is known about factors associated with the receipt of medication information among arthritis patients. This study explores information source receipt and associations between demographic and clinical/patient characteristics and the amount of arthritis medication information patients receive. Adult patients with osteoarthritis (OA) or rheumatoid arthritis (RA; n = 328) completed an online cross-sectional survey. Patients reported demographic and clinical/patient characteristics and the amount of arthritis medication information received from 15 information sources. Bivariate and multivariate linear regression analyses were used to investigate whether those characteristics were associated with the amount of medication information patients received. Arthritis patients received the most information from health professionals, followed by printed materials, media sources, and interpersonal sources. Greater receipt of information was associated with greater medication adherence, taking more medications, greater medication-taking concerns, more satisfaction with doctor medication-related support, and Black compared to White race. RA patients reported receiving more information compared to OA patients, and differences were found between RA patients and OA patients in characteristics associated with more information receipt. In conclusion, arthritis patients received the most medication information from professional sources, and both positive (e.g., greater satisfaction with doctor support) and negative (e.g., more medication-taking concerns) characteristics were associated with receiving more medication information.

Evaluating cognitive effort in a randomized controlled trial

Many randomized controlled trials (RCTs) of neuropsychiatric conditions involve cognitive outcome measures; however, validity of cognitive data relies on adequate effort during testing, and such screening is seldom performed. Given well-established rates of 10 to 30% poor effort in clinical settings, this is not a trivial concern. This preliminary study evaluated effort during cognitive testing in an RCT of omega-3 supplementation to reduce suicidality in a high-risk psychiatric population. An interim analysis of sustained attentions measures from the Connors Performance Test (CPT-2) at baseline for the first 60 participants was conducted. Previously validated cut points to detect insufficient effort on the CPT-2 were applied. At baseline, 12% (7) were identified as giving poor effort. Follow-up analyses indicated less psychiatric distress and suicidality among those who gave poor effort. Results suggest comparable likelihood of a poor effort on cognitive testing in clinical and RCT participation. Reduced psychiatric distress in the poor effort group raises concern regarding interpretation of other measures. The importance of screening cognitive data for effort in RCTs is highlighted. Future studies will examine effort at follow-up visits, and explore relationships to attrition, adherence, and response to treatment. Copyright © 2016 John Wiley & Sons, Ltd.

"Beat the Shock Clock": An Interprofessional Team Improves Pediatric Septic Shock Care

Ideal care for septic shock (SS) is difficult. This interprofessional quality improvement intervention in a mid-volume pediatric emergency department aimed to reduce time to vascular access, fluid resuscitation, and antibiotics for SS. Intensive education, a care pathway, and an order set were applied. Outcome measures for patients with criteria for SS before and after intervention were compared. There were 43 patients pre-intervention (January 2009 to June 2011) and 63 post-intervention (June 2012 to June 2013). Median time to vascular access decreased from 37 minutes pre-intervention to 24 minutes post-intervention (p = 0.05). Median time to first fluid bolus decreased from 35 to 26 minutes (p = 0.08). Percentage of boluses delivered rapidly by pressure method increased from 21% to 74% (p < 0.0001). Median time to antibiotics decreased from 92 to 55 minutes (p = 0.02). In conclusion, a multimodal, interprofessional quality improvement intervention in a mid-sized pediatric emergency department improved the time to critical interventions for SS.

Maternal Versus Infant Vitamin D Supplementation During Lactation: A Randomized Controlled Trial

OBJECTIVE

Compare effectiveness of maternal vitamin D3 supplementation with 6400 IU per day alone to maternal and infant supplementation with 400 IU per day.

METHODS

Exclusively lactating women living in Charleston, SC, or Rochester, NY, at 4 to 6 weeks postpartum were randomized to either 400, 2400, or 6400 IU vitamin D3/day for 6 months. Breastfeeding infants in 400 IU group received oral 400 IU vitamin D3/day; infants in 2400 and 6400 IU groups received 0 IU/day (placebo). Vitamin D deficiency was defined as 25-hydroxy-vitamin D (25(OH)D) <50 nmol/L. 2400 IU group ended in 2009 as greater infant deficiency occurred. Maternal serum vitamin D, 25(OH)D, calcium, and phosphorus concentrations and urinary calcium/creatinine ratios were measured at baseline then monthly, and infant blood parameters were measured at baseline and months 4 and 7.

RESULTS

Of the 334 mother-infant pairs in 400 IU and 6400 IU groups at enrollment, 216 (64.7%) were still breastfeeding at visit 1; 148 (44.3%) continued full breastfeeding to 4 months and 95 (28.4%) to 7 months. Vitamin D deficiency in breastfeeding infants was greatly affected by race. Compared with 400 IU vitamin D3 per day, 6400 IU/day safely and significantly increased maternal vitamin D and 25(OH)D from baseline (P < .0001). Compared with breastfeeding infant 25(OH)D in the 400 IU group receiving supplement, infants in the 6400 IU group whose mothers only received supplement did not differ.

CONCLUSIONS

Maternal vitamin D supplementation with 6400 IU/day safely supplies breast milk with adequate vitamin D to satisfy her nursing infant's requirement and offers an alternate strategy to direct infant supplementation.